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Antenatal Booking Form - St George Hospital
Antenatal Booking Form for St George Hospital
Last/Surname
First/Given Name
Previous or Maiden Name
Date of Birth
Date
Do you identify as Aboriginal or Torres Strait Islander?
- None -
Aboriginal Origin
Torres Strait Islander
Both Aboriginal/Torres St Isl. Origin
Neither Aboriginal/Torres St Isl.
Not Specified
Country of Birth
Language spoken at Home
Interpreter Needed
Marital Status
- None -
Single
Widow
Never married
Married / De facto
Separated
Divorced
Religion
Occupation
Is this your first baby?
- None -
Yes
No
Last menstrual period
Date
Expected date of Delivery
Date
Current number of weeks pregnant
Contact Details
Street
Suburb
State and postcode
Email address
Home
Mobile
Work
Emergency Contact
Contact Name
Relationship
Phone Number
Insurance
Medicare Number
Private Health Insurance
- Select a value -
Yes
No
Fund Name
Fund Number
GP Details
GP Name
Practice
Phone
GP Email
Antenatal Care
Have you attended this Hospital Before?
- None -
Yes
No
If yes, under what surname?
Have you previously received pregnancy care at St George or Sutherland Hospital
- None -
Yes
No
Which clinic did you attend?
- None -
ANC St George
ANC Sutherland
Birth Centre
GP Shared Care
HIgh Risk
MGP/STOMP
Would you like Antenatal Shared Care with your GP & the hospital?
- None -
Yes
No
Are you interested in the Midwifery Group Practice (MGP) for your pregnancy care?
- None -
Yes
No
Are you interested in the Active Birth Team (ABT) for your pregnancy care (previous Birth Centre Care)?
- None -
Yes
No
Has your GP discussed and organised Nuchal Translucency for you?
- None -
Yes
No
Has you GP discussed and organised Genetic Counselling for you?
- None -
Yes
No
Has you GP discussed and organised a Dating Scan for you (if period date uncertain)?
- None -
Yes
No
Medical/Pregnancy History
Type 1 Diabetes?
- None -
Yes
No
Currently pregnant with twins?
- None -
Yes
No
Baby born before 34 weeks of pregnancy?
- None -
Yes
No
Blood pressure problems?
- None -
Yes
No
Epilepsy?
- None -
Yes
No
Kidney disease?
- None -
Yes
No
Pre-eclampsia in a previous pregnancy?
- None -
Yes
No
Do you have any other medical conditions that may impact your pregnancy care?
Preferred Appointment Day
- None -
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Appointment AM/PM
- None -
Any
AM
PM
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