Date of Birth
Care Package Chosen AmazonianGoddessWarriorQueenATM
Price: £8,300
Price: £7,600
Price: £3,800 – £4,500
Price: £1,800
Price: £250
Estimated Due Date
Date of booking appointment
DOB
Admissions to ITU or A&E (past 12 months)
Anaesthetic problems
Autoimmune disease
Blood transfusions
Blood or clotting disorders
Cancer
Cardiac Disease
Chicken Pox or Shingles
Diabetes
Exposure to Toxic Substances
Epilepsy
Essential hypertension (High Blood Pressure)
Fertility Challenges (this pregnancy)
Gynae history/Operations
Gastro-intestinal disorders
Genital infections (EG-Herpes, Chlamydia, STIs)
Incontinence or Pelvic floor problems
Infections (EG GBS, MRSA)
Inherited Disorders
Liver disease
Kidney disease
Muscular/Skeletal issues Including Back
Operations
DVT/PE/Thrombosis
Migraines/Severe Headaches
Pelvic injury
Respiratory problems
Bleeding in this pregnancy
Thyroid/endocrine disorders
TB exposure
Date:
Weight:
Gestation:
Type of Birth:
Place of birth:
Name:
Still births:
Number of previous live births:
Multiple birth
Eclampsia
Caesarean section
GBS +ve
Gestation 37 wks
PPH (excessive blood loss after birth) 1000mls
Gestation >42 wks.
3rd/4th degree tear
Previous baby >4.5kg
Gestational diabetes
Breech
Pulmonary Embolism (PE)
IUGR/SGA
APH (Bleeding in pregnancy or labour)
Birth defect
Cord prolapse
Shoulder dystocia
Obstetric Cholestasis
Hypertension
Pre-eclampsia
Booking-Date bloods taken
MSU (Mid stream Urine)
Haemoglobin (HB)
Blood Group
Antibodies
Sickle Cell
Thalassemia
Rubella
Hepatitis B
Syphilis
HIV
Random Blood Glucose
Others
GTT (OGTT)
