Date of Birth
Care Package Chosen AmazonianGoddessWarriorQueenATMBespoke
Price: £8,300
Price: £7,600
Price: £3,800 – £4,500
Price: £1,800
Price: £250
Price: £150
Height:
Weight:
BMI
Occupation
Country of Birth
Ethnic Origin
Smoker(optional)Select any optionYesNo
Smoking Prior to Pregnancy (optional)Select any optionYesNo
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
Alcohol: Are you currently consuming any alcohol? (optional)Select any optionYesNo
Prior to pregnancy? (optional)Select any optionYesNo
DOB
Birth Weight
Gestation at Birth
Place of Birth
Type of Birth
Have you had any pregnancy losses? (optional)Select any optionYesNo
Nature Select any optionMiscTOPStillbirthNature Select any optionMiscTOPStillbirthNature Select any optionMiscTOPStillbirth
Do you have a history or any ongoing sexual abuse?Select any optionYesNo
Do you have a history or any ongoing domestic abuse?Select any optionYesNo
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
Early Pregnancy/Viability ScanNuchal/Dating Scan (10-14 weeks)Anomaly ScanAny Other Scans
Have you had or have you considered any vaccinations in this pregnancy?Select any optionYesNo
Flu VaccineSelect any optionYesNo
Whooping Cough VaccineSelect any optionYesNo
Covid VaccineSelect any optionYesNo
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
