Antenatal Questionnaire - Complete Physio Clinics London

Full Name*

First Last

How many weeks pregnant are you?*

What is your due date?*

Where are you having your baby?*

Where are you receiving your midwifery care?*

Are you under the care of a Consultant? and if so who?*

Are you expecting twins or triplets?*

Yes
No

Have you had any scan results? 12 week, 20 week or other and if so what were the results?*

Do you have a cervical stitch in place?*

Yes
No

Has your pregnancy been assisted in any way (e.g. IVF)?*

Yes
No

Do you have gestational diabetes?*

Yes
No

Have you ever had placenta praevia / low lying placenta?*

Yes
No

Have you ever had a miscarriage?*

Yes
No

Please give details of any previous deliveries

Child 1 Age

Method of delivery e.g. vaginal, caesarean, forceps, ventouse

Any complications

What is the weight of your heaviest baby?

Do you have any other children?*

Yes
No

Child 2 Age

Method of delivery e.g. vaginal, caesarean, forceps, ventouse

Any complications

Weight of baby

Do you have any other children?

Yes
No

Child 3 Age

Method of delivery e.g. vaginal, caesarean, forceps, ventouse

Any complications

Weight of baby

Do you have any other children?

Yes
No

Child 4 Age

Method of delivery e.g. vaginal, caesarean, forceps, ventouse

Any complications

Weight of baby

Are you planning on having anymore children?*

Yes
No

Do you ever experience leakage of urine and/ or stool?*

Yes
No

Do you ever feel urgency from the bladder and/ or bowel?*

Yes
No

Do you suffer from constipation or regularly strain on the toilet?*

Yes
No

Do you have any difficulties emptying from the bladder or bowel?*

Yes
No

Do you have any difficulty controlling wind?*

Yes
No

Do you experience pain in your vulva or vagina with or without sex?*

Yes
No

Do you experience a sensation of pressure or heaviness in your vagina or rectum or ever noticed a bulge inside?*

Yes
No

Have you experienced any of the following: (Please tick)*