Folic acid in pregnancy patient questionnaire

Dear patient,

If you are pregnant and have made a self-referral to the Midwife for a booking appointment it is important that you are taking the correct dose of folic acid. All women should take 400microgram daily of folic acid from 3 months before conception up to 12 weeks pregnant. Some women need a higher 5mg dose of folic acid which can only be prescribed.

Please complete the following to assess if you might need a higher dose of folic acid. Please mark the appropriate answer.

If you answer YES to any of the questions in section A-G you WILL need folic acid 5mg (Milligrams) which you cannot buy over the counter.

If you do not require the higher 5mg (Milligrams) dose we will still issue you a prescription for the normal 400mcg (micrograms) dose on prescription.

You should return to the practice 48 hours after submitting your completed form and collect a prescription. If you have a nominated pharmacy your prescription will be sent there.

Folic acid in pregnancy patient questionnaire

Are you completing this form on behalf of:

Yourself

Someone else

What is your relationship to the patient?

Your first name

Your surname

Your date of birth

Your address

Your post code

Your mobile phone telephone number

Your email address

This email address may be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see the response you sent.

Are you happy for us to contact you by SMS text message or email?

Date of last menstrual period? (LMP) If not known, best guess?

What is your height? (in centimetres)

We require accurate weight. Document if weight is estimated or actual weight

What is your weight? (In kilograms) Require actual weight

Is the weight you provided an actual or estimated wight?

A. Body mass index score (BMI)Practice staff to calculate score.

B. Is there any history in your family of neural tube defects? E.g. Spina Bifida or Anencephaly

C. Do you have diabetes?

D. Do you have Coeliac disease?

E. Are you taking Epilepsy Medication for any reason?

F. Are you taking Thyroid Medication?

G. Do you have Thalassaemia or Sickle Cell Anaemia?

Do you have a history of Sleeve Gastrectomy?

Has the patient made a self referral to the antenatal clinic via WHSCT Website?www.westerntrust.hscni.net/service/maternity-services (referral form to be completed and emailed by patient directly to Midwives.)

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Park Medical • Great James Street Health Centre, Great James Street, Derry, BT48 7DH.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Local Services

Aesthetic
Clinic

Macmillan
Cancer Support

Your Service
Here