Patient Pregnancy Form

Please complete this form if you would like to inform the surgery that you are pregnant. Please complete in as much detail as possible so we can ensure you get any required treatment and appropriate advice. If you have any queries or concerns about your pregnancy, then please do contact the surgery to arrange an appointment with a GP or visit A&E.

For more information on pregnancy, please follow the link: www.nhs.uk/pregnancy

Patient Pregnancy Form

Section

Please use this date format: DD/MM/YYYY
Do you currently have any symptoms that you are concerned about i.e. bleeding/pain/sickness?
Do you have any ongoing medical problems or are you on any regular medication?
Did you have any problems in your previous pregnancy? (if applicable)
Are you taking any pregnancy vitamins which contain Folic Acid and Vitamin D?

Please enter your current height and weight below. This is to get updated BMI. This is not essential to be filled in.