First Contact Client Information and Initial Consultation
Date
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Month
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Day
Year
Date
Name
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Phone Number
Preferred method of contact
GP Surgery
Preferred or Named GP
Pregnancy Details
Estimated Due Date
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Month
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Day
Year
Date
Parity (total number of pregnancies excluding this one)
Miscarriage history (number of losses before 24 weeks pregnancy)
Previous Pregnancies
please skip this section if it does not apply to you
Previous Pregnancies: please tell us when your babies were born, how many weeks pregnant you were, and how much they weighed.
Birth Interventions: please detail any interventions you had during birth including Caesarean section, antibiotics, induction, etc
Type of Births
Spontaneous vaginal birth (head down)
Spontaneous breech birth
Ventouse assisted birth
Forceps assisted birth (head down)
Forceps assisted birth (breech)
Caesarean Section
Other
Type of Births: please detail where and how your babies were born. i.e. at home vaginally, head down.
Feeding history: how did you feed your babies? Was this positive experience?
Mother's Medical History
Previous Medical Problems: please list anything you saw a hospital doctor for more than once, and anything else involving your physical or mental health you feel might be relevant. Include dates where possible.
Current Medical Problems please list any current physical and mental health issues both related to and not related to pregnancy and birth
Current Medication; please list all medications you are currently taking and the dosage
Do you have anything else you would like to share with us that you haven't mentioned above?
Our Services
How did you hear about us?
Why did you contact us? Are there services you are particularly interested in?
Do you have any questions for us?
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