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Miss Claire Mellon & Associates is now open in accordance with Government guidelines

Learn more

Our Team
Our Specialities
- Gynaecology
- Obstetrics
Wellness Space
Fees
- Payments
FAQs
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Online Bookings

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Request Repeat Prescription

New Antenatal Patient Questionnaire

Full name

Birthday

Day

Month

Year

Current concerns / reasons for making the appointment:

Current pregnancy

Have you had a scan in this pregnancy?

Yes

No

Estimated delivery due date on ultrasound:

Was this a spontaneous pregnancy or assisted conception? (Spontaneous/ Assisted conception)

Obstetric and Gynaecology History

Date of last menstrual period

Date of last cervical smear

Any past gynaecological problems or infections?

Do you have any children? (How many? / Caesarean Section or Normal Delivery?)

Have you had any other pregnancies? (e.g. Miscarriage / ectopic pregnancy)

Have you ever had a baby before 37 weeks? (Please specify)

Medical History

What is your current weight?

How tall are you?

Ethnicity

Do you have any medical problems? (Please specify)

Have you had any major operations? (Please specify)

Are you on any regular medications? (Please specify)

Do you have any allergies? (Please specify)

Do you smoke? (How many per day)

Alcohol consumption? (Minimal / Moderate / Above average)

Family history

Diabetes

Yes

No

High blood pressure

Yes

No

Pre-eclampsia

Yes

No

Blood clots in leg or lung

Yes

No

Sickle cell disease

Yes

No

Anaesthetic problems

Yes

No

Cystic fibrosis

Yes

No

Are there any other medical problems that run in your family (please specify)

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