Early pregnancy unit - new patient form

Please detail your reason for referral with as much detail as possible.

Have you had a positive pregnancy test? Required

None

Yes

Do you have pain? Required

Yes

If your pain is severe and you are not able to carry out daily activity, please attend the Emergency Department for assessment.

Do you have vaginal bleeding? Required

Yes

If your bleeding is heavy and you are soaking through more than 1 sanitary pad an hour, then please attend Emergency Department for assessment.

When was your first day of your last menstrual period?

How many weeks pregnant are you?

Have you had a scan in this pregnancy? Required

Have you previously had an ectopic pregnancy, recurrent miscarriage (three or more consecutive), or a previous molar pregnancy? Required

Any other enquiry related to early pregnancy complications:

Personal details

First name Required

Last name Required

Preferred contact number Required

Email address Required

Address Required

Address 1

Address 2

City

Country

County

Postal Code

Date of birth Required

NHS number Required

Details of GP

GP surgery Required

Postcode

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