Congratulations on your Pregnancy! Name DrMissMrMrsMsProf.Rev. Title First Last Date of Birth Day Month Year Address Flat Number/House Name Street/Road Name Postcode Contact numberWhat was the 1st Day of your last period Day Optional Month Optional Year Optional If not known, how many weeks pregnant do you think you may be? OptionalFolic AcidYou should be taking 400mcg of folic acid until you are 13 weeks pregnant. To assess whether a higher dose of folic acid is required for you, please complete the following fields.Height(ft / in)Weight(kg)Are you a diabetic? Yes No Are you on medication for epilepsy? Yes No Are you currently taking any other medications? If yes please list below Yes No List of medications OptionalNeural Tube DefectNeural Tube Defect is a birth defect affecting the brain, spine or spinal cord.Have you or your partner got a condition known as neural tube defect? Yes No Unknown Have you had a previous baby with neural tube defect? Yes No Unknown Have you or your partner got anybody in your family with a neural tube defect? Yes No Unknown By completing this form online you consent to the handling and storage of the data by this website. The surgery will not contact you unless any further information is required I agree to the privacy policySignature OptionalFor further information on how to self refer to the midwife team at the countess of chester copy and paste the link below Optional Phone OptionalThis field is for validation purposes and should be left unchanged.
