Obstetric History Form

Preparing for Your First Consultation

The following information can help make the most of your first consultation with your Midwife and Obstetrician. Completing this form is optional, and you are welcome to discuss any concerns directly with your Obstetrician if you prefer.

Name

First Name

Last Name

Mobile Number

(###)

###

####

Email Address

Have you had any miscarriages or early pregnancy losses?

If yes, please provide details below

Miscarriages or early pregnancy losses details

Please include dates if known

Record 1

Date of Birth

Gestation at Birth

Place of Birth

Name of Child

Birth Weight

Sex of Child

Pregnancy Complications

(Hyperemesis / Gestational Diabetes / High Blood Pressure / Iron Deficiency / Other)

Labour

(Spontaneous / Induction / NA)

Analgesia

(Gas / Morphine / Epidural / Other)

Birth Method

(Vaginal Birth / Forceps / Vacuum Extraction / Caesarean Section)

Additional Notes

ADD SECOND CHILD RECORD?

Record 2

Date of Birth

Gestation at Birth

Place of Birth

Name of Child

Birth Weight

Sex of Child

Pregnancy Complications

(Hyperemesis / Gestational Diabetes / High Blood Pressure / Iron Deficiency / Other)

Labour

(Spontaneous / Induction / NA)

Analgesia

(Gas / Morphine / Epidural / Other)

Birth Method

(Vaginal Birth / Forceps / Vacuum Extraction / Caesarean Section)

Additional Notes

ADD THIRD CHILD RECORD?

Record 3

Date of Birth

Gestation at Birth

Place of Birth

Name of Child

Birth Weight

Sex of Child

Pregnancy Complications

(Hyperemesis / Gestational Diabetes / High Blood Pressure / Iron Deficiency / Other)

Labour

(Spontaneous / Induction / NA)

Analgesia

(Gas / Morphine / Epidural / Other)

Birth Method

(Vaginal Birth / Forceps / Vacuum Extraction / Caesarean Section)

Additional Notes

ADD FOURTH CHILD RECORD?

Record 4

Date of Birth

Gestation at Birth

Place of Birth

Name of Child

Birth Weight

Sex of Child

Pregnancy Complications

(Hyperemesis / Gestational Diabetes / High Blood Pressure / Iron Deficiency / Other)

Labour

(Spontaneous / Induction / NA)

Analgesia

(Gas / Morphine / Epidural / Other)

Birth Method

(Vaginal Birth / Forceps / Vacuum Extraction / Caesarean Section)

Additional Notes

ADD FIFTH CHILD RECORD?

Record 5

Date of Birth

Gestation at Birth

Place of Birth

Name of Child

Birth Weight

Sex of Child

Pregnancy Complications

(Hyperemesis / Gestational Diabetes / High Blood Pressure / Iron Deficiency / Other)

Labour

(Spontaneous / Induction / NA)

Analgesia

(Gas / Morphine / Epidural / Other)

Birth Method

(Vaginal Birth / Forceps / Vacuum Extraction / Caesarean Section)

Additional Notes

Talk with our experienced team has the knowledge and compassion to care for you and your baby, We would love hear from you and answers any questions you may have contact.