ANTENATAL ASSESSMENT AND REFERRAL FORM

ANTENATAL ASSESSMENT AND REFERRAL FORMPlease complete both sides of the form (this information is confidential and will only be shared with other professionals in discussion with you)Surname:Date of Birth:Forename: GP Name: PCT code:Address:Address:Telephone No:Postcode:Telephone Number:Postcode:NHS No:Home:Mobile:Hospital Number:Work (optional)Previous Name:Previous Address:Post code:Smokes Yes/NoPartners Name:Address:Telephone number:Smokes Yes/NoDate of Birth:LMP……………………. Menstrual Cycle: Regular (#days …….) / Irregular EDD from LMP………………………..Folic Acid Taken: Yes/No – if yes: pre conception/ post conceptionHeight……………….. Weight ………………………..Obstetric History (parity, previous deliveries)BMI…………….Gender of last baby: M/FWeight……………………….Gestation…………Place of Birth…………………………………RISK INDICATORS FOR SAFEGUARDING CHILDREN (CONSIDER LIFE EVENTS AND SIGNIFICANT EPISODES THIS WOMAN MAY HAVE HAD PRIOR TOPREGNANCY WHICH MAY IMPACT ON THE ABILITY TO PARENT)Drug/Alcohol Misuse YES/NO Mental Health Problems Yes/No Previous or current contact with Social Care YES/NOAny children subject to a child protection plan now or in the past? YES/NOAre previous children living with mother YES/NOIf any concerns, have they been discussed with woman YES/ NOReferral to social care department YES/NOInformation sharing form required YES/NOOther Agency referral YES/NOKC 10/11 KMG 2.3Other agency known to be involved YES/NO (please specify if yes)…………………………………

Ethnic origin…………………….…….. Learning difficulties YES/NO English first language YES/NO Is interpreter required YES/NOARE ANY OF THE FOLLOWING PRESENT? YES/NOPlease tick as appropriate Maternal request for initial consultation. 40 years or over at booking Booking BP diastolic > 90mm/Hg systolic> 140 mm/hg or any known hypertensive disorder. Women who are particularly vulnerable ( see risk factors previous page). BMI >35 or < 18 Women with current or past history of mental illness Any other existing or previous medical problems which may complicate pregnancy e.g. diabetes, thromboembolic disorders,epilepsy. Please refer to booking guideline. Specify below.……………………………………………………………………………………………………………………………………………………………………………………………………Previous operations that may complicate pregnancy Cone biopsy (under GA) Pelvic floor repair Hysterotomy Surgery for urinary or faecal incontinence OtherObstetric History Previous 3 rd or 4 th degree perineal laceration Preterm delivery < 37 weeks Low birth weight 4.5Kg Grand multiparity> 6pregnancies LSCS Previous HELPP syndrome Eclampsia or severe pre eclampsia Previous IUGR Previous fetal abnormality 3 or more consecutive miscarriages Red cell antibodies Previous stillbirth, neonatal death or late miscarriage Puerperal psychosis Previous APH causing maternal/fetal compromise PPH > 1 litre or requiring blood transfusionIt is advised that these women have an Obstetric review in antenatal clinic to plan appropriate care pathwaysPlease indicate most appropriate location for booking appointment LISTER QEII Hertford countyPlease indicate if Consultant appointment required Planned place of birth: CLU HOME MLUMIDWIVES BOOKING ASSESSMENTAssessment completed by……………………….Named Midwife…………………………………….Date of Assessment: ………………………….Midwifery Team………………..……….Please provide further information on following:Non Smoker/Smoker – if smoker how many per day? ……. was a referral made? Yes/No if ex‐smoker when quit ……………Partner: Smoker/Non smoker – if smoker how many per day? ………Discussion of Choices Shared GP/Midwifery care Consultant care Dating scan Combined screening Anomaly scan Appointment with AN screening co‐ordinator ……………………………………………………. Appointment with Consultant Midwife Previous Consultant if known ……………………….APPOINTMENT: Hospital use only Consultant: Midwives booking: Date: Time: Location: