Did you have any illnesses or problems during the pregnancy?Did you have any illnesses or problems during the pregnancy?YesNo
If so please explain
Please select if you have had any of the following tests or scans (Hold ctrl/cmd to select multiple answers)Please select if you have had any of the following tests or scans (Hold ctrl/cmd to select multiple answers)Early Viability Scan (dating/viability) - NHSEarly Viability Scan (dating/viability) - PrivateCombined Test (Nuchal Scan and Blood Test) - NHSCombined Test (Nuchal Scan and Blood Test) - PrivateQuad Test (bloods 15-18wks if not had Combined Screening) - NHSQuad Test (bloods 15-18wks if not had Combined Screening) - PrivateNIPT (NiftyHarmonyPanorama) - NHSNIPT (NiftyHarmonyPanorama) - PrivateAnomaly Scan - NHSAnomaly Scan - PrivateCardiac Scan - NHSCardiac Scan - PrivateWellbeing Scans after 24 weeks - NHSWellbeing Scans after 24 weeks - Private4D Baby Bonding Scan - NHS4D Baby Bonding Scan - PrivateAmniocentesis - NHSAmniocentesis - PrivateCVS - NHSCVS - PrivateGroup B Strep Screening (rectovaginal swabs) - NHSGroup B Strep Screening (rectovaginal swabs) - PrivateCervical Scan - NHSCervical Scan - PrivateFetal Fibronectin (pre-term labour screening) - NHSFetal Fibronectin (pre-term labour screening) - Private
Other? Please explain
Outcome
What was the outcome of the pregnancy?What was the outcome of the pregnancy?LivebirthStillbirthMiscarriageMedication TerminationSurgical Termination
If not a Livebirth, please explain what happened
Date of Delivery
Gestation (0-44 weeks)
Where did you deliver?
How did you deliver?How did you deliver?Vaginal (spontaneous)Vaginal (induced)Caesarean (elective)Caesarean (emergency)
Baby
If the following are applicable then please complete this section of the form. Use both sections A and B for twins.
How many babies did you have?How many babies did you have?1234
Baby A
Baby SexBaby SexMaleFemale
Baby Weight (lbs and oz)
Full Name
Hospital Number
NHS Number
Apgar Score (At 1, 5 and 10 minutes eg. 3,4,7)
Was the baby admitted to SCBU?Was the baby admitted to SCBU?YesNo
If so, why?
When did the baby come home? (dd/mm/yy and how many days old?)
Does the baby have any problems?Does the baby have any problems?YesNo
Baby B
Our Clinic
What test(s) or service(s) did you use?
How would you describe your experience with us?
Would you be happy for us to share your anonymised clinic experience on our website etc?Would you be happy for us to share your anonymised clinic experience on our website etc?YesNo
5 + 3 = ?Please prove that you are human by solving the equation *
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