










REASON | DATE ADMITTED | NO.DAYS STAYED | |
---|---|---|---|
Generic textHow manyGeneric dateGeneric textHow manyGeneric dateHow manyGeneric dateGeneric text | Generic textHow manyGeneric dateGeneric textHow manyGeneric dateHow manyGeneric dateGeneric text | Generic textHow manyGeneric dateGeneric textHow manyGeneric dateHow manyGeneric dateGeneric text | |
1 | |||
2 | |||
3 | |||
4 | |||
5 |




- | |
---|---|
1 - Almost all the time 2 - Sometimes 3 - Not at all |
|
painful stitches | |
backache | |
headaches or migraines | |
urinary infection | |
nausea | |
vomiting | |
diarrhoea | |
haemorrhoids or piles | |
infected nipple(s) | |
other breast problem | |
feeling weepy/tearful | |
feeling irritable | |
feeling exhausted | |
varicose veins | |
passing urine very often | |
problem holding urine when you jump, sneeze etc | |
indigestion | |
feeling dizzy/fainting | |
flashing lights/spots before eyes | |
shoulder ache | |
tingling in hands/fingers | |
tingling in feet/toes | |
neck ache | |
feeling depressed |

Check: Have you included herbal remedies, sleeping pills, vitamins, cough medicines, pain killers, iron tablets, homeopathic medicines, the contraceptive pill.









What is the present job situation of yourself and your partner? Yourself
What is the present job situation of yourself and your partner? Your partner
(Please answer for each person regularly involved.)
- | If yes, give hours per week | and Age of baby when this began (in weeks) | |
---|---|---|---|
Hours per week 1 - No 2 - Yes Age in weeksHours per week1 - No 2 - Yes Age in weeks1 - No 2 - Yes Age in weeksHours per week |
Hours per week 1 - No 2 - Yes Age in weeksHours per week1 - No 2 - Yes Age in weeks1 - No 2 - Yes Age in weeksHours per week |
Hours per week 1 - No 2 - Yes Age in weeksHours per week1 - No 2 - Yes Age in weeks1 - No 2 - Yes Age in weeksHours per week |
|
partner | |||
baby's grandparent | |||
other relative | |||
friend/neighbour | |||
paid person outside your home (e.g. child minder) | |||
paid person in your home (eg. nanny, baby sitter) | |||
day nursery (creche) | |||
other (please describe) |








alspac_91_mamb
SECTION A: LABOUR AND DELIVERY
Who did you have with you?
in labour | during delivery | |
---|---|---|
1 - Yes 2 - No 1 - Yes 2 - No 1 - Yes 2 - No 1 - Yes 2 - No |
1 - Yes 2 - No 1 - Yes 2 - No 1 - Yes 2 - No 1 - Yes 2 - No |
|
my husband/partner | ||
my mother | ||
other friend or relative |
DENTAL CARE
SECTION B: YOUR HEALTH AND LIFESTYLE IN PREGNANCY
give for each admission:
REASON | DATE ADMITTED | NO.DAYS STAYED | |
---|---|---|---|
Generic textHow manyGeneric dateGeneric textHow manyGeneric dateHow manyGeneric dateGeneric text | Generic textHow manyGeneric dateGeneric textHow manyGeneric dateHow manyGeneric dateGeneric text | Generic textHow manyGeneric dateGeneric textHow manyGeneric dateHow manyGeneric dateGeneric text | |
1 | |||
2 | |||
3 | |||
4 | |||
5 |
Did you smoke regularly in the last 2 months of pregnancy and since having the baby?
Last 2 months of pregnancy | Since having the baby | |
---|---|---|
1 - Yes 2 - No 1 - Yes 2 - No 1 - Yes 2 - No 1 - Yes 2 - No |
1 - Yes 2 - No 1 - Yes 2 - No 1 - Yes 2 - No 1 - Yes 2 - No |
|
cigarettes | ||
pipe | ||
cigar | ||
other |
SECTION C: YOUR HEALTH NOW
Since having the baby have the following occurred?
- | |
---|---|
1 - Almost all the time 2 - Sometimes 3 - Not at all |
|
painful stitches | |
backache | |
headaches or migraines | |
urinary infection | |
nausea | |
vomiting | |
diarrhoea | |
haemorrhoids or piles | |
infected nipple(s) | |
other breast problem | |
feeling weepy/tearful | |
feeling irritable | |
feeling exhausted | |
varicose veins | |
passing urine very often | |
problem holding urine when you jump, sneeze etc | |
indigestion | |
feeling dizzy/fainting | |
flashing lights/spots before eyes | |
shoulder ache | |
tingling in hands/fingers | |
tingling in feet/toes | |
neck ache | |
feeling depressed |
Please name all the pills, medicines or ointments you are currently using or have used since the baby was born.
What did you take: | About how many days did you take or use it? | |
---|---|---|
How manyGeneric textHow manyGeneric text | How manyGeneric textHow manyGeneric text | |
1 | ||
2 | ||
3 | ||
4 | ||
5 | ||
6 | ||
7 | ||
8 | ||
9 | ||
10 |