Health Questionnaire

Please complete this ahead of your appointment with From Bumps 2 Babies.

Your name

Telephone number

Address

Email address

Your expected date of baby to be born / The date that your baby was born

Baby number (1/2/3/4+)

Midwife or Consultant led

Where are you planning to give birth / where was your baby born?

Did you have any problems during your pregnancy?

Do you have any allergies?

Do you have any past medical history that I need to know about?

Do you have any past obstetric history that you would like to tell me about?

How is your current mental health?

What is the reason you have booked to see me today?

What are you looking to achieve from our appointment?

IF PREGNANT - Do you know the location of your placenta?

IF PREGNANT - Have you arranged your birth classes yet?

IF HAD BABY - Did you have any problems during your labour or birth?

IF HAD BABY - How was your birth experience and what was the mode of birth? I.e. natural / assisted / caesarean

IF HAD BABY - Has your scar healed well? (Caesarean birth only)

If you have booked a massage, please confirm that you do not have any of the following before you attend:If you have booked a massage, please confirm that you do not have any of the following before you attend:I do not have Athletes footI do not have a nut allergyI do not have vaginal bleedingI do not have low lying placentaI do not have skin rash or broken skinI do not have high temperatureI do not feel unwell