Toggle Contract

Self-Registration Form for Maternity Care

Please complete all mandatory fields marked with *. Failure to do so may slow down the processing of your registration. Please share with us any information that you think is relevant to providing care for yourself or your baby. The answers you provide will allow us to pass your registration to the correct Midwifery or Obstetric Team; therefore it is essential that you share as much information as possible.

Registrations can also be made by calling your local community midwives’ office on (Aylesbury) 01296 316120 or (High Wycombe) 01494 425172.

Please send all completed Self-Registration forms to bht.maternityreferrals@nhs.net – Thank You.

SELF REGISTRATION FORM

Are you completing this form on behalf of someone else?

Yes No

If No, please continue to "mother’s information"

If Yes,

What is your name?

What is your relationship to the mother?

Does the mother need help from a translator?

Yes No

If yes, which language?

What method of assistance does the mother require with communication, e.g. help with reading or through sign language?

Please be aware we do not advise family or friends to translate on behalf of pregnant women during an appointment.

MOTHER'S INFORMATION

Title:

Ms Mrs Miss Other

Full Name*:

Maiden Name (if applicable):

Date of Birth*:

NHS Number (If known):

Address*:

Postcode*:

Telephone Number*:

Email:

Name of GP Surgery*:

Name of GP*:

PREVIOUS PREGNANCY INFORMATION

Total number of previous pregnancies (including the current pregnancy and any pregnancy loss)*:

Number of pregnancy losses less than 12 weeks:

Number of pregnancy losses after 12 weeks:

Any complications during previous pregnancies or births?*:

Yes No

If Yes, what issues did you encounter? Please give details below: (E.g. diabetes, raised blood pressure, obstetric cholestasis or excessive bleeding…..)

Previous Birth Information:
Please include

DoB:
Place of Birth:
Vaginal or Caesarean:
Gestation at delivery:
Is the child alive and well?:

Do you take regular medication?*:

Yes No

If yes, please give details below:

Have you ever experienced Diabetes?*:

Yes No

Have you ever experienced Thyroid problems?*:

Yes No

Have you ever suffered with any mental health concerns, such as depression, anxiety?*:

Yes No

If yes, please give details below:

If you answered "Yes" to Diabetes or Thyroid problems, please give details below:

CURRENT PREGNANCY INFORMATION

Do you know the date of the 1st day of your last period?*:

Yes No

If yes, what was the 1st day of your last period?*:

Have you thought about where would you like to birth your baby?* :

Home Wycombe Birth Centre Aylesbury Birth Centre Stoke Mandeville Hospital Labour Ward

At a different NHS Trust, please state where:

Estimated Due Date (if known):

Any information relating to this pregnancy or your past medical history that you think may be useful:

Have you ever had support from a social or family support worker?*:

Yes No

Do you currently drink more than 14 units of alcohol a week?*:

Yes No

Do you smoke tobacco?*:

Yes No

Have you ever taken recreational drugs?*:

Yes No

If you answered "Yes" to any questions above, please give details below:

Thank you for your enquiry, we will be in touch shortly.

Self-Registration Form for Maternity Care

SELF REGISTRATION FORM

MOTHER'S INFORMATION

PREVIOUS PREGNANCY INFORMATION

MEDICAL HISTORY

CURRENT PREGNANCY INFORMATION

SOCIAL HISTORY