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Antenatal Appointment Form - Sutherland Hospital
Antenatal Appointment Form for Sutherland Hospital
Surname
Given Name
Previous or Maiden Name
Date of Birth
Date
Aboriginality Status
- None -
Aboriginal Origin
Torres Strait Islander
Both Aboriginal/Torres St Isl. Origin
Neither Aboriginal/Torres St Isl.
Not Specified
Does your partner identify as Aboriginal or Torres Strait Islander?
- None -
Yes
No
Country of Birth
Language spoken at Home
Interpreter Needed
Marital Status
- None -
Single
Widow
Never married
Married / De facto
Separated
Divorced
Religion
Occupation
Is this your first baby?
- None -
Yes
No
Last menstrual period
Date
Expected date of Delivery
Date
Current number of weeks pregnant
Medicare Number
Billing Status
- None -
Overseas (no Medicare)
Reciprocal
Medicare
Current Address
Street
Suburb
State and postcode
Email
Email address
Contact Numbers
Home
Mobile
Work
Person to contact
Emergency Contact - Name
Emergency Contact - Relationship
Emergency Contact - Phone Number
Insurance
Private Insurance
- None -
Top
Basic
Nill
Fund Name
Fund Number
GP Details
GP Name
Practice
Phone
Antenatal Care
Have you attended Sutherland Hospital before?
- None -
Yes
No
If yes, under what surname?
Have you previously received pregnancy care at St George or Sutherland Hospital
- None -
Yes
No
Which clinic did you attend?
- None -
ANC St George
ANC Sutherland
Birth Centre
GP Shared Care
HIgh Risk
MGP/STOMP
Has your GP discussed and organised Nuchal Translucency for you?
- None -
Yes
No
Has you GP discussed and organised Genetic Counselling for you?
- None -
Yes
No
Has you GP discussed and organised a Dating Scan for you (if period date uncertain)?
- None -
Yes
No
Are you planning a home birth with a private midwife?
- None -
Yes
No
Model of Care
Preferred model of care
- None -
Midwifery group practice (MGP)
MAPS
New Directions for Indigenous mothers and babies
GP Shared Care
Medical History
Type 1 / Type 2 Diabetes?
- None -
Type 1
Type 2
No
High blood pressure?
- None -
Yes
No
Epilepsy?
- None -
Yes
No
Kidney or liver disease?
- None -
Yes
No
Auto Immune Disease?
- None -
Yes
No
Mental Health concerns?
- None -
Yes
No
Do you have any medical concerns?
Pregnancy History
Current or previous pregnancy concerns for early referral?
- None -
Yes
No
Currently pregnant with twins or triplets?
- None -
Yes
No
Past preterm birth (under 34 weeks)?
- None -
Yes
No
Past pregnancy cervical suture or pessaries to reduce?
- None -
Yes
No
Risk of preterm birth?
- None -
Yes
No
Previous hyperemesis?
- None -
Yes
No
Previous loss at greater than 18 weeks gestation?
- None -
Yes
No
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