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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:

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.

We require accurate weight. Document if weight is estimated or actual weight
Practice staff to calculate score.
www.westerntrust.hscni.net/service/maternity-services (referral form to be completed and emailed by patient directly to Midwives.)

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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.

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.


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Park Medical

Great James Street Health Centre, Great James Street, Derry, BT48 7DH

  • 028 7137 8500
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Advertise Your Business Here FREE
Attendance
Allowance -
info here
Local Services
Financial help if 66yrs+ and have medical condition
Power of
Attorney
Advertise Your Business Here FREE
Attendance
Allowance -
info here
Local Services
Financial help if 66yrs+ and have medical condition
Power of
Attorney
Advertise Your Business Here FREE
Attendance
Allowance -
info here