Reason for referral:
Current pregnancy
Age:
Gestation:
Conception:
Body mass index:
Obstetric complications
1)
2)
3)
Obstetric history
Parity:
Previous pregnancies:
Previous pregnancy complications:
Medical history
1)
2)
3)
Surgical history
1)
2)
3)
Family history
1)
Medication
1)
2)
3)
Allergies
1)
Investigations
Haemoglobin:
Combined screening:
Anomaly scan:
Uterine artery Dopplers:
Risk assessments
VTE:
PET:
GDM:
Examination
Fetal heart:
SFH:
Physical examination:
Blood pressure:
Urinalysis:
Mental wellbeing:
Plan
1)
2)
3)
4)
Follow-up:
Resources:
Useful notes (O&G, MFM) 