BOOKING FORM



    AmazonianGoddessWarriorQueenATM

    Price: £8,300
    Price: £7,600
    Price: £3,800 – £4,500
    Price: £1,800
    Price: £250

    BASIC INFO

    GP


    PARTNER


    NEXT OF KIN

    PERSONAL INFO

    NEXT OF KIN

    MEDICAL HISTORY (CURRENT AND PREVIOUS)

    Tick for Yes, Cross for No
    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

    PREVIOUS PREGNANCIES

    Details of previous births:








    PREVIOUS PREGNANCY EVENTS.

    Tick for Yes. Cross for No
    Multiple birth
    Eclampsia
    Caesarean section
    GBS +ve
    Gestation 37 wks
    Gastro-intestinal disorders
    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

    CURRENT PREGNANCY

    Blood results:













    Blood results:




    TO BE COMPLETED BY MIDWIFE
    ADDITIONAL INFORMATION







    Height/Weight/EthnicityParity and obs hxEDB
    PRISM insurance
    Contract signed
    Stickers

    Private Midwives in South London