Date of Birth
Care Package Chosen AmazonianGoddessWarriorQueenATMBespoke [group ama-package] Price: £8,300 [/group]
[group god-package] Price: £7,600 [/group]
[group warrior-package] Price: £3,800 – £4,500 [/group]
[group queen-package] Price: £1,800 [/group]
[group atm-package] Price: £250 [/group]
[group Bespoke-package] Price: £150 [/group]
Height:
Weight:
BMI
Occupation
Country of Birth
Ethnic Origin
Smoker(optional)Select any optionYesNo[group is_smoker] [/group]
Smoking Prior to Pregnancy (optional)Select any optionYesNo [group stop_smoking][/group]
Drugs: Have you ever used any drugs which have not been prescribed by a health care professional or bought over the counter? (optional)Select any optionYesNo[group stop_Drugs][/group]
Alcohol: Are you currently consuming any alcohol? (optional)Select any optionYesNo[group Alcohol][/group]
Prior to pregnancy? (optional)Select any optionYesNo[group Prior ][/group]
DOB
Birth Weight
Gestation at Birth
Place of Birth
Type of Birth
Have you had any pregnancy losses? (optional)Select any optionYesNo [group Loss]Nature Select any optionMiscTOPStillbirthNature Select any optionMiscTOPStillbirthNature Select any optionMiscTOPStillbirth[/group]
Do you have a history or any ongoing sexual abuse?Select any optionYesNo[group history][/group]
Do you have a history or any ongoing domestic abuse?Select any optionYesNo[group domestic][/group]
Mental health– Do you have any current or historical mental health diagnosis you wish to share? Please include any triggers, treatments, or medication – the more information the better.
Have you had any scans so far in this pregnancy?Select any optionYesNo[group Scans]Early Pregnancy/Viability ScanNuchal/Dating Scan (10-14 weeks)Anomaly ScanAny Other Scans[/group]
Have you had or have you considered any vaccinations in this pregnancy?Select any optionYesNo[group Vaccinations]Flu VaccineSelect any optionYesNo[group Vaccine][/group]Whooping Cough VaccineSelect any optionYesNo[group Whooping][/group] Covid VaccineSelect any optionYesNo[group Covid_Vaccine] [/group][/group]
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
Private Midwives in South London
