Pregnancy referral form

It is important you fill out this form as fully and as honestly as possible. This will ensure we can offer the most appropriate care for you and your baby.
Would you like to deliver your baby at West Suffolk Hospital?
If you have selected 'no' above please name the hospital you are referring to, or type 'home birth' if you are considering a home birth.

if you have answered 'Yes' interpreter required please state which language you require

Health information
Are you transferring from another Trust?
If you are transferring from another Trust and answered 'Yes' to the question above, please tell us which Trust you are coming from:
If you have had a dating scan, what is your estimated due date?
Do you have diabetes?
Are you a smoker?
Date of last period (DD/MM/YYYY)
If you are uncertain of your last period date, please give reason for uncertainty?
Any history of other medical or pregnancy related conditions?
Have you been pregnant before?
How many births have you had?
Have you had a Caesarean section before?
If you have had a Caesarean, how many have you had?
Have you experienced an early pregnancy loss before?
If you have experienced three or more miscarriages, have they been consecutive? (i.e. have you experienced 3 miscarriages or more in a row?)

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