Self-Registration Form for Maternity Care

Please share with us any information that you think is relevant to providing care for yourself or your baby. The answers you provide will allow us to pass your registration to the correct Midwifery or Obstetric Team; therefore it is essential that you share as much information as possible.

Registrations can also be made by calling your local community midwives’ office on (Aylesbury) 01296 316120 or (High Wycombe) 01494 425172.

Please do not use this service for any urgent medical queries as this service is only monitored during practice working hours on a daily basis.

Please note: If you have an urgent medical query you should telephone the surgery or contact the out of hours service by calling 111.

Self-Registration Form for Maternity Care
Are you completing this form on behalf of someone else?
Does the mother need help from a translator?
Please be aware we do not advise family or friends to translate on behalf of pregnant women during an appointment.
Continue on to Mother's Information

Mother's Information

Title:
Please use date format DD/MM/YYYY
Any responses will be sent to this email address
Available from your GP
Have you been pregnant before (including any pregnancy loss)? *

Previous Pregnancy Information

Previous Birth Information

If more than 4 pregnancies, please only put the 4 most recent.

1.

Vaginal or Caesarean:
Is the child alive and well?
2.
Vaginal or Caesarean:
Is the child alive and well?
3.
Vaginal or Caesarean:
Is the child alive and well?
4.
Vaginal or Caesarean:
Is the child alive and well?
Any complications during previous pregnancies or births? *

Medical History

Do you take regular medication? *
Have you ever suffered with any mental health concerns, such as depression or anxiety? *
Have you ever experienced either of the following?
Diabetes: *
Thyroid problems: *

Current Pregnancy Information

Do you know the date of the 1st day of your last period? *

Social History

Have you ever had support from a social or family support worker? *
Do you smoke tobacco? *
Do you currently drink more than 14 units of alcohol a week? *
Have you ever taken recreational drugs? *

Office Use Only