Maternity Consultation Form Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Date of BirthAddressPhoneGP AddressNo of weeks pregnant on first visitExpected Due DateObsteric Care Giver NameObsteric Care GiverMidwifeGPConsultantContact DetailsThis PregnancyPlannedNaturally conceivedFirst pregnancyScanOkAdditional DetailsDo you /have you suffered from any of the followingBackacheRib PainSymphisis pubisGroin PainBraxton HicksVaginal BleedingMorning SicknessHeartburnPlacenta Praevai *ConstipationDiarroheaFreq of MicturationCystisisProtein/blood/sugar in urinePalpitationsAmnesiaLeg pain/crampsVaricose veinsDVT *HaemorrioidsLow BPHigh BP*OedemaPanic attacksCarpel TunnelSciaticaHeadaches *Stretch marksItchy SkinTender breastsFatigueDiabetes *Mood swingsInsomniaPrevious Pregnancies - 1Normal PregnancyAilments sufferedPre termOn TimeOverdueNormal DeliveryEpiduralAssisted DeliveryStitchesPost-natel problemsMiscarriage/terminationsPrevious Pregnancies - 2Normal PregnancyAilments sufferedPre termOn TimeOverdueNormal DeliveryEpiduralAssisted DeliveryStitchesPost-natel problemsMiscarriage/terminationsPrevious Pregnancies - 3Normal PregnancyAilments sufferedPre termOn TimeOverdueNormal DeliveryEpiduralAssisted DeliveryStitchesPost-natel problemsMiscarriage/terminationsPrevious Pregnancies - 4Normal PregnancyAilments sufferedPre termOn TimeOverdueNormal DeliveryEpiduralAssisted DeliveryStitchesPost-natel problemsMiscarriage/terminationsReason for ReflexologyExpectations of ReflexologyAny other informationHow did you hear about Blissfully Calm?Would you like to join our Email list to receive news and special offers?YesNoConsent *YesNoI understand that the reflexology treatment I am about to receive is specially to help throughout pregnancy. I am happy for Sharon to proceed with treatmentSigned *Dated *Send Form