










Reason | Date admitted | Number of days stayed | |
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5 |
Check Have you included the contraceptive pill, iron tablets, laxatives, vitamins, sleeping tablets, aspirin, cough mixture, pain killers, indigestion tablets, herbal medicine?
What did you take: (give exact name if you can) | About how many days did you take or use it? | How many weeks pregnant were you? | |
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How manyHow manyGeneric textHow manyHow manyGeneric textHow manyGeneric textHow many | How manyHow manyGeneric textHow manyHow manyGeneric textHow manyGeneric textHow many | How manyHow manyGeneric textHow manyHow manyGeneric textHow manyGeneric textHow many | |
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10 |


- | |
---|---|
1 - Never or rarely 2 - Once in 2 weeks 3 - 1 - 3 times a week 4 - 4 - 7 times a week 5 - More than once a day |
|
Sausages, Burgers | |
Pies, Pasties (pork pie, steak/meat pie etc.) | |
Meat (beef, lamb, pork, ham, bacon etc.) | |
Poultry (chicken, turkey etc) | |
Liver, liver pate, kidney, heart | |
White fish (cod, haddock, plaice, fish fingers etc) | |
Other fish (pilchards, sardines, mackerel, tuna, herring, kippers, trout, salmon etc) | |
Shellfish (prawns, crab, cockles, mussels etc) | |
Eggs, quiche | |
Cheese | |
Pizza | |
Chips | |
Roast potatoes (cooked in fat) | |
Boiled, mashed, jacket potatoes | |
Rice (boiled) | |
Pasta (eg. spaghetti, Pot Noodles, lasagna) | |
Crisps | |
Fried foods (eg. fried fish, eggs, bacon, chops etc) |
- | |
---|---|
1 - Never or rarely 2 - Once in 2 weeks 3 - 1 - 3 times a week 4 - 4 - 7 times a week 5 - More than once a day |
|
Baked beans | |
Peas, sweetcorn, broad beans | |
Cabbage, brussel sprouts, kale and other green leafy vegetables | |
Other green vegetables (cauliflower, runner beans, leeks etc) | |
Carrots | |
Other root vegetables (turnip,swede,parsnip etc) | |
Salad (lettuce, tomato, cucumber etc) | |
Fresh fruit (apple, pear, banana, orange, bunch of grapes etc) | |
Tinned juice (including tomato juice) | |
Pure juice not in tin | |
Pudding (eg fruit pie, crumble, cheesecake, milk pudding, mousse, gateaux) | |
Oat cereals (eg porridge, Ready Brek, muesli) | |
Wholegrain or bran cereals (eg. All Bran, Bran Flakes, Weetabix, Wheatflakes, Fruit & Fibre) | |
Other cereals (eg Cornflakes, Rice Krispies, Special K, Frosties) | |
Cakes or buns (fruit cake, sponge, teacake, buns, doughnut, flapjack, scone, custard tart, cream cake etc) | |
Crispbreads (Ryvita, crackerbread etc) | |
Biscuits (digestive, shortcake, Hob Nobs, Rich Tea, Nice, Marie, chocolate biscuits, Penguin, Club, Kit Kat etc) | |
Chocolate bars (Mars, Twix, Wispa, Bounty, Creme Egg etc) | |
Pulses - dried peas, beans, lentils, chick peas | |
Nuts, nut roast | |
Bean Curd (eg. Tofu, miso) | |
Tahini | |
Soya 'Meat', T.V.P., Vegeburgers | |
Chocolate (dairy milk or plain, nut, fruit filled etc) | |
Sweets (peppermints, boiled sweets, toffees etc) |
On bread or vegetables | For frying | |
---|---|---|
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 |
|
Butter, Ghee, Dripping Lard, solid cooking fat | ||
Hard or soft margarine e.g. Blue Band, Stork, supermarket own brand | ||
Polyunsaturated margarine e.g. Flora, sunflower, Vitalite | ||
Low fat spread e.g. Outline, Delight, St.Ivel Gold | ||
Sunflower, soya, corn, olive oil | ||
Other vegetable oil | ||
Other (please describe) |














- | |
---|---|
1 - Yes |
|
CSE or GCSE (D, E, F or G) | |
O-level or GCSE (A, B or C) | |
A-level | |
Qualifications in shorthand/typing/or other skills, e.g. hairdressing | |
Apprenticeship | |
State enrolled nurse | |
State registered nurse | |
City & Guilds intermediate technical | |
City & Guilds final technical | |
City & Guilds full technical | |
Teaching qualification | |
University degree | |
No qualifications | |
Qualifications not known | |
Not applicable, no such person |
- | |
---|---|
1 - Yes |
|
CSE or GCSE (D, E, F or G) | |
O-level or GCSE (A, B or C) | |
A-level | |
Qualifications in shorthand/typing/or other skills, e.g. hairdressing | |
Apprenticeship | |
State enrolled nurse | |
State registered nurse | |
City & Guilds intermediate technical | |
City & Guilds final technical | |
City & Guilds full technical | |
Teaching qualification | |
University degree | |
No qualifications | |
Qualifications not known | |
Not applicable, no such person |
- | |
---|---|
1 - Yes |
|
CSE or GCSE (D, E, F or G) | |
O-level or GCSE (A, B or C) | |
A-level | |
Qualifications in shorthand/typing/or other skills, e.g. hairdressing | |
Apprenticeship | |
State enrolled nurse | |
State registered nurse | |
City & Guilds intermediate technical | |
City & Guilds final technical | |
City & Guilds full technical | |
Teaching qualification | |
University degree | |
No qualifications | |
Qualifications not known | |
Not applicable, no such person |
- | |
---|---|
1 - Yes |
|
CSE or GCSE (D, E, F or G) | |
O-level or GCSE (A, B or C) | |
A-level | |
Qualifications in shorthand/typing/or other skills, e.g. hairdressing | |
Apprenticeship | |
State enrolled nurse | |
State registered nurse | |
City & Guilds intermediate technical | |
City & Guilds final technical | |
City & Guilds full technical | |
Teaching qualification | |
University degree | |
No qualifications | |
Qualifications not known | |
Not applicable, no such person |

Please tick all that apply.
- | |
---|---|
1 - Yes |
|
Working for an employer full-time (more than 30 hours a week) | |
Working for an employer part-time (one hour or more a week) | |
Self-employed, employing other people | |
Self-employed, not employing other people | |
On a government employment or training scheme | |
Waiting to start a job already accepted | |
Unemployed and looking for a job | |
At school or in other full-time education | |
Unable to work because of long-term sickness or disability | |
Retired from paid work | |
Looking after the home or family |
Please tick all that apply.
- | |
---|---|
1 - Yes |
|
Working for an employer full-time (more than 30 hours a week) | |
Working for an employer part-time (one hour or more a week) | |
Self-employed, employing other people | |
Self-employed, not employing other people | |
On a government employment or training scheme | |
Waiting to start a job already accepted | |
Unemployed and looking for a job | |
At school or in other full-time education | |
Unable to work because of long-term sickness or disability | |
Retired from paid work | |
Looking after the home or family |

















alspac_91_yp
SECTION A: PLANS AND EXPECTATIONS
How much do you want to know about what might happen during labour?
- | |
---|---|
1 - Yes 2 - No |
|
I'd rather not know anything | |
I just want to know the basics | |
I want to know most things but not things that will upset or worry me | |
I'm happy to let the staff decide how much I ought to know | |
I want to know as much as possible |
SECTION B: YOUR PRESENT HEALTH
give reason for each admission:
Reason | Date admitted | Number of days stayed | |
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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 |
In the last 3 months have you used any medicines, pills or ointments for the following:
- | |
---|---|
1 - Yes, in last 3 months 2 - No, not in last 3 months 9 - Don't know |
|
nausea | |
heartburn | |
vomiting | |
anxiety | |
infection | |
migraine | |
difficulty going to sleep | |
pain | |
allergies | |
skin condition | |
bleeding | |
depression | |
piles | |
constipation | |
cough |
Please indicate how often you have taken the following pills in the last three months
- | |
---|---|
1 - Every day 2 - Most days 3 - Sometimes 4 - Not at all |
|
aspirin | |
paracetamol | |
codeine/anadin | |
mogadon, or other sleeping tablets | |
valium, or other tranquillisers |
Please describe all pills, medicines and ointments you have taken or used in the past 3 months, including those listed above.
What did you take: (give exact name if you can) | About how many days did you take or use it? | How many weeks pregnant were you? | |
---|---|---|---|
How manyHow manyGeneric textHow manyHow manyGeneric textHow manyGeneric textHow many | How manyHow manyGeneric textHow manyHow manyGeneric textHow manyGeneric textHow many | How manyHow manyGeneric textHow manyHow manyGeneric textHow manyGeneric textHo |