Hushee Pregnancy & Postnatal Health Questionnaire & Consent Form

*First name

*Last name

Email

*Phone

*Emergency Name & Contact Number:

Pregnancy Questions

Baby's Due Date:

Relevant conditions: (please tick if apply)

High blood pressure

Gestational diabetes

Pre-eclampsia

Pelvic pain (SPD/PGP)

Other:

Please state below:

Midwife/Consultant Care:

Baby's Date of Birth:

Birth Method:

Postnatal Questions:

Health Factors: (please tick):

C-section recovery

Pelvic floor concerns

Abdominal separation

Feeding challenges

Other:

Please state below:

General Wellbeing:

Long-term conditions or medications?

Anything else you'd like me to know?

Consent:

I understand this is not medical advice

I will listen to my body and communicate any changes

Signature:

Date:

Contact Me

1B Western Road

Shoreham-by-Sea

West Sussex

BN43 5WD

Tel: 07951290334

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