Early Pregnancy Assessment Clinic self-referral for Bristol and Weston-super-Mare

Please read

If you are having significant abdominal pain, heavy vaginal bleeding, and/or are feeling faint or dizzy, then do not continue to complete this form, and instead seek urgent medical attention by contacting your GP, out of hours doctor service, attending the accident and emergency department, or dialling 999 in an emergency.

Have you been treated for an early pregnancy issue within the last 8 weeks?

Yes

Are you under the care of the recurrent miscarriage clinic?

Yes

Please select which hospital you were seen at

Please choose in which hospital you would like to receive your care

Early Pregnancy Assessment Unit Self-Referral Form

Please fill in as much information as you can. If you need help, ask your GP. Important:

If you have heavy bleeding, bad abdominal pain, or dizziness, do not fill out this form. Seek urgent medical attention by contacting your GP, out of hours doctor service or dialling 999/ attending the accident and emergency department.
This form is only for people who are 6 weeks pregnant or more. If you are less than 6 weeks pregnant, please see your GP.
This service is not for regular pregnancy check-ups or booking your pregnancy care.

Note that these forms will be reviewed between 8am and 2.30pm Mondays to Fridays.
If you submit a form after 2.30pm on a Friday, you may not get a response until the following Monday. Note that forms will not be reviewed on Bank Holidays.

Please provide your details

First name:

Last name:

Date of birth:

Address line 1

Postcode

Phone number:

Do you need an translator?

Yes

Which language?

Do you have a disability?

Yes

Please tell us any accommodations or adjustments that may be needed for us to provide you the best care

Are you the patient, or referring on behalf of a patient, as a healthcare provider?

I am the patient

I am referring on behalf of a patient

Other

Friend/Relative

Other primary care practitioner

Midwife

Emergency department practitioner

111 call handler

Private ultrasound provider

Fertility clinic

Termination care provider

Please tell us about this pregnancy

Have you had a positive pregnancy test?

Yes

Please complete a pregnancy test

You can only refer yourself to the Early Pregnancy Assessment Clinic if you have had a positive pregnancy test. If the test result is negative and you still have symptoms, please contact your GP for advice.

When was the first day of your last menstrual period?

Is this an IVF pregnancy?

Yes

Date of embryo transfer

What was the age of the embryo at transfer?

Have you had a scan in this pregnancy?

Yes

Where and when did you have a scan?

What did the scan show?

Are you planning on continuing with this pregnancy?

Yes

Unsure

Your symptoms

Please select all that apply.

Do you have any abdominal pain?

Yes

Please describe the location and severity of the pain

Questions	No pain	Mild	Moderate	Severe
General lower abdomen	No pain	Mild	Moderate	Severe
Right lower abdomen	No pain	Mild	Moderate	Severe
Left lower abdomen	No pain	Mild	Moderate	Severe
Back pain	No pain	Mild	Moderate	Severe
Shoulder tip pain	No pain	Mild	Moderate	Severe

Do you have any vaginal bleeding?

Yes

Please describe the heaviness of the bleeding?

Spotting

Light bleeding e.g. on wiping

Like a period

Heavier than a period e.g. passing large clots

I have not had any vaginal bleeding

When did this episode of bleeding start?

Have you had any of the following symptoms?

Pain or stinging when passing urine

Diarrhoea

Feeling faint or dizzy

Unusual vaginal discharge

Constipation

None of the above

Do you have any other symptoms you are concerned about?

Previous pregnancies

Please tell us about previous pregnancies

How many children do you have?

How many miscarriages have you had?

How many ectopic pregnancies have you had?

How many terminations have you had?

Have you ever experienced any of the following?

Molar pregnancy

Miscarriage at 12-24 weeks

Stillborn baby after 24 weeks

Neonatal death or death of an older child

None of the above

Additional questions (optional)

You do not need to complete this information but it may be helpful for us to assess your symptoms

Are you currently taking any medications?

Yes

Please give details about medication

Have you ever had a previous pelvic infection?

Yes

Please give details

Have you ever had a thrombosis?

Yes

I don't know

What is a thrombosis?

A thrombosis is a blood clot inside a blood vessel, for example in the legs or lungs

Please give details

Do you have any medical conditions or any previous surgery?

Yes

Please give details

Did you get pregnant whilst using any of the following?

Is there anything else you would like us to know?

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