NSW Government NSW Health
South Eastern Sydney Local Health District
nsw health

PLaN Questionnaire

PLAN logoPLaN (Pre-Conception Planning, Lifestyle and Nutrition) is a new service at the Royal Hospital for Women, Randwick and Sydney Hospital. Women and their partners can access information regarding pregnancy planning. The service is free and is staffed by a midwife and a doctor who will advise you regarding fertility issues, conception, health, nutrition and lifestyle requirements.

PLaN staff are available at Royal Hospital for Women on the 2nd and 4th Wednesday of each month and at Sydney Hospital on the 1st and 3rd Wednesday  of each month.
"Not Pregnant, Just Looking" are information sessions held in the evening every few months at the Royal Hospital  for Women so that women and their partners can access pregnancy planning information including options of pregnancy care in a group setting.

To register for the PLaN programme we would ask you to answer the following questions.

The information will be submitted to our midwife via email and she will contact you to arrange a full PLaN session to suit your requirements.

* = mandatory fields

How old are you? * Years
What is your post code? *
Do you speak a language other than English at home? * Yes No
If so, what language?

 


Other:
How much do you weigh?  kg
What is your height? cm
Do you smoke? Yes No
If so, how many cigarettes per day?
Do you drink alcohol regularly? Yes No
If so, how many drinks in an average week?
Are you taking any multivitamins or folic acid now?  Yes No
If so, which one(s)? 
Do you know how much folic acid it contains?      mg
Do you currently have a GP?  Yes No
Have you already started trying to get pregnant? * Yes No
Do you have any medical  conditions that may impact on your ability to conceive or on a pregnancy? * Yes No
If you have a medical condition please provide brief details:
Do you have any questions you would like to ask the PLaN staff?
How did you find this site? *
If you wish to participate in PLaN please indicate how you wish to access the service.
Name *
Email address *
Telephone numbers:  
Mobile
Home
Do you want to register for the "Not Pregnant, Just Looking" evening seminar? Yes No
I would like to make an appointment to see PLaN staff * Yes No
I will need an interpreter (language required is addressed in next line) * Yes No
If interpreter required, which language ?

Other

 

If you prefer to phone to make an appointment to see our PLaN staff at Royal Hospital for Women or Sydney Hospital please call 02 9382 6382 .

If you wish to come along to our next "Not pregnant just looking" information session please call  02 9382 6382 to confirm your spot (a small fee may be charged for the session)