Booking

Full name(required)

Email(required)

Phone(required)

Address(required)

Date of Birth(required)

Country of birth(required)

Spoken language/s(required)

Translator required?(required) Yes

No

Ethnic group

Religion

Occupation(required)

Emergency contact person (Name and Mobile)(required)

Partner’s name

Partner’s date of birth

Partner’s ethnic group

Residency Status(required) Citizen

Permanent Resident

Visitors Visa – Please provide a copy of your passport

Work Visa – Please provide a copy of your passport

Other – Please provide a copy of your passport

Eligible for free care?(required) Yes

No

Unsure

Height (cm)(required)

Weight (kg)(required)

Doctors name/practice(required)

When was your last smear test?(required)

What were the results of your smear? Normal

Abnormal

Unsure

Is this a twin or multiple pregnancy?(required) Yes

No

Unsure

Did you have fertility treatment to assist your pregnancy?(required) Yes

No

Is this your first pregnancy?(required) Yes

No

If no, how many pregnancies have you had?

Do you have other children? If so how many?

First day of your last period?(required)

Due date

Are your periods regular? Every 28 days lasting 7 days? If not please specify(required)

Have you had any blood tests during this pregnancy?(required) Yes

No

Have you had any scans during this pregnancy?(required) No

Yes at Focus Ultrasound

Yes at Bay Radiology

Yes at Medex radiology

Yes at Bethlehem Ultrasound

Yes. Other radiologist

Do you have any history of medical conditions, operations, gynaecological problems or treatment to your cervix?(required) Yes

No

Unsure

If yes, provide details below:

Have you experienced any of the following? Vaginal bleeding

Abdominal pain

Severe vomiting

Provide details here of the above or any other concerns?

Smoking. Tick whichever may apply:(required) Non Smoker

Smoker

Partner Non Smoker

Partner Smoker

House smoke free

Consent to Quit smoking support

If you are a smoker, how many cigarettes do you smoke per day?

Other lifestyle/health factors. Tick whichever may apply: Diabetic

Drinking Alcohol

Marijuana

Other substances

Notes regarding any of the above. Please also note your dietary requirements, e.g Vegetarian.

Past pregnancies and birth. Tick whichever may apply.(required) First pregnancy

Previous miscarriages

Previous terminations

Previous Caesarean

Stillbirth

Ectopic pregnancy

Previous normal birth(s)

Notes regarding any of the above. Please note how many children you have if any.

Previous birth details. Please number your births and write; the date of birth, place of birth, how many weeks pregnant you were at the birth, how many hours in labour, any complications, birth weight, how long you breastfed for and if you and baby were well after the birth for EACH delivery.

Where do you plan to birth your baby?(required) Home

Bethlehem Birthing Unit

Tauranga hospital

Unsure

Your medical history. Tick whichever may apply:(required) Rheumatic fever

Heart disease

Asthma

Autoimmune problems

Hormonal issues

Tuberculosis

Thyroid problems

Lung disorder

STD

Diabetes

Gastro-Intestinal

Infertility

Genetic disorder

Liver disorder

Psychiatric

Depression

High blood pressure

Renal/Kidney

UTI’s

Incontinence

Blood clotting problems

Blood disorder

Drug allergies

Previous anaesthetic

Varicose veins

Bone disorder

Birth defects

Neurological issues

Joint disorder

Allergies

None of the above

Your medical history. Please write any detailed notes here.

List current medications, including folic acid and iodine:(required)

Any previous surgeries or anaesthetics? Please also note when they were done if so.

Are you adopted?(required) Yes

No

Are you allergic to any drugs or anything else?(required) Yes

No

Details of allergies:

Would you accept blood products should you need them? Yes

No

Unsure

Family medical history (your family and father of child and family)(required) Heart condition

Diabetes

Hypertension

Blood/Blood clotting disorder

Epilepsy

Asthma

Tuberculosis

Renal/Kidney problems

Cancer

Spina Bifida

Clicky hips

Cleft palate

Cerebral Palsy

Neural Tube Defect

Congential Conditions

Eczema

Deafness

Malignant Hyperthermia

Psychiatric

Depression

Allergies

No to all

Family medical history notes

Family mental health history notes

Booking

Please complete the booking form

Call to arrange a short phone consultation

Please complete the booking form

Call to arrange a short phone consultation

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