Please complete the form below. If you’d prefer to fill it out offline, you can download the form by clicking here.
Patient’s Name: Date of Birth:
Partner’s Name (if applicable):
First Appointment Date:
Please tick if you are happy to receive information regarding pregnancy by SMSEmail
Do you have any allergies? (e.g. medicine, adhesive tape, foods)NoYes
If yes, please specify details:
Date of your last cervical screening test:Result: Normal Abnormal
Detail any treatment required:
Please list any medications you are taking, including prescription, over-the-counter, vitamins, folate.
Do you smoke?NoYes Amount per day:
Do you drink alcohol?NoYesAmount per week:
Have you had a blood transfusionNoYesYearReason
How would you describe your diet? (e.g. vegetarian, vegan, healthy, unhealthy)
Do you exercise?
NoYesIf yes, what type and how often
What is your height? cm
What was your pre pregnancy weight? kg
Have you had any previous pregnancy? * Yes No Please fill out this field.
Date of Birth
Hospital
Gestation (weeks)
Outcome
Labour
Duration of labour
Pain relief medication
Birth type
Baby weight
Baby name
Baby sex
Feeding method
I have read and understood the Privacy Consent Document and consent to the collection and use of my health information.
During your appointment, your doctor may use secure AI software (Heidi AI) to assist with medical note-taking. All notes are reviewed by your doctor, no audio is stored, and your information is handled in accordance with Australian privacy laws. By proceeding, you consent to its use.
I consent to photographs being taken during my visit, if requested by my doctor, for marketing purposes only. I understand that I have the right to review and approve any images before they are used in any promotional or marketing material.
