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Self-referral for pregnancy care - Northwick Park Hospital

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Maternity self-referral form
Personal details
Interpreter required?
Marital status
Partner's details
GP details
Current pregnancy
Past obstetric history (make note of any previous caesarean section, assisted delivery, and pregnancy outcomes)
Medical and psychiatric history (if answer is Yes to any of the following, please provide further details using the 'additional information' section)
Heart problems
Neurological
Lung/asthma/TB
Diabetes
Sickle Cell/Thalassaemia
Kidney problems
High blood pressure
Liver problems
Mental health problems
Other
Social history (if answer is Yes to any of the following, please provide further details using the 'additional information' section)
Drug/alcohol misuse (including partner)
Violence/domestic abuse
Child protection issues
Do you have a social worker
Any other mental health concerns
Disability eg deaf/blind/physical handicap
Smoked in last six months?
Current medication
Folic acid
Vitamin D
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