Page Congential Heart Disease by nikeborome

VIEWS: 10 PAGES: 21

									     Electronic Encyclopaedia of Perinatal Data (EEPD)
                 Volume 18. Questionnaires




     Bolton Antenatal
Booking History Questionaire
                                 Dataset Version.




    As in use in June 2007. Available for viewing only
   Not to be used without the permission of the creators

                              Made accessible in this format by
                            Rupert Fawdry, FRCS (Ed), FRCOG.
             Consultant Specialist in Maternity Care, Gynaecology and Medical IT
 General Editor: Electronic Encyclopaedia of Perinatal Data (EEPD) Web site: www.fawdry.info
               31, St.Mary’s Way, Leighton Buzzard, LU7 2RX, United Kingdom
                       Home: 01525 37 01 37 Mobile: 077 678 23 827
                             e-mail: eepd@fawdry.demon.co.uk



            Any Comments, Criticisms, Corrections
        or Suggestions for Improvement very welcome


                                                                                     Page1
                                                                                         out of 21

                                   EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
                                      Page 1
MATERNITY AND WOMEN’S HEALTH CARE DIRECTORATE
ANTENATAL BOOKING HISTORY QUESTIONNAIRE
Unit Number
Title
First Name
Date of Birth
Place of Birth
Address
Postcode
Occupation
Religion
Partner’s Name
Address
Postcode
GP (Pregnancy Care)
Address
Postcode
Telephone Number
Next of Kin
Address
Postcode
Telephone Number
Consultant
Interviewing Midwife
Interpreter Present
Booking Date (Home)
Postcode
Telephone Number
Relationship
Address
Bolton Hospitals
Surname
Maiden Name
Age
Marital Status
Telephone Number (Home)
Telephone Number (Work)
Telephone Number
Occupation
GP (Usual Care)
Address
Postcode
Telephone Number
Named Midwife
Interview Difficulties
Booking Date (Hospital)




                                                                               Page2
                                                                                   out of 21

                                 EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
                                      Page 2.
Hypertension in past/No treatment
Hypertension in past/Treated
WHAT IS YOUR RACE OR ETHNIC ORIGIN?
White/British
White/lrish
White/ Any other background
Black/Caribbean
Black/ African
Black/ Any other background
Mixed/White and Black Caribbean
Mixed/White and Black African
Bangladeshi
Indian
Pakistani
Chinese
Asian/ Any other background
Any other ethnic group
Unknown
Don’t know
I do not wish to answer




                                                                              Page3
                                                                                  out of 21

                                  EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
WHAT IS YOUR PARTNER’S RACE OR ETHNIC ORIGIN?
White/British
White/lrish
White/ Any other background
Black/Caribbean
Black/ African
Black/ Any other background
Mixed/White and Black Caribbean
Mixed/White and Black African
Bangladeshi
Indian
Pakistani
Chinese
Asian/ Any other background
Any other ethnic group
Unknown
Don’t know
I do not wish to answer

IS YOUR PARTNER A BLOOD RELATIVE?
NO
Yes

HAVE YOU ANY PHYSICAL IMPAIRMENT?
NO
Wheelchair user
Partially sighted
Blind

HAVE YOU EVER HAD ANY HEART PROBLEMS?
NO
Cardiac surgery
Congenital heart disease
Heart Disease
Heart Murmur in Childhood
Mixed/White and Asian
Mixed/Any other background
Partial loss of hearing
Deaf with speech
Deaf without speech
Other
Heart murmurhecent
Ischaemic heart disease
Rheumatic Fever
Scarlet Fever
Valve lesion

HAVE YOU EVER HAD RAISED BLOOD PRESSURE OTHER THAN DURING PREGNANCY?
Hypertension/Current treatment
Hypertension on contraceptive pill
Other
                                                                                  Page4
                                                                                      out of 21

                                    EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
                                            Page 3
HAVE YOU EVER HAD VARICOSE VEINS OR BLOOD CLOTTING PROBLEMS?
NO
Bleeding at the dentist
Cerebral Vascular Accident
DVT/Not anticoagulated
DVT / Anticoagulated

HAVE YOU EVER HAD URINARY TRACT OR KIDNEY PROBLEMS?
NO
Congenital abnormality of kidney
Glomerulonephritis
IVP
Nephrectomy
Nephrotic Syndrome
Pyel onephritis
Pulmonary Embolus
Superficial Phlebitis
Varicose veins/Not treated
Varicose veins/Treated
Other

HAVE YOU EVER HAD ENDOCRINE PROBLEMS OR INVESTIGATIONS?
NO
Diabetes/Diet controlled
Diabetes/On insulin
Diabetes/On tablets
Gestational Diabetes
Endocrine disease
GTT/No treatment

HAVE YOU EVER HAD FITS, EPILEPSY OR A DISEASE
NO
Akinetic Epilepsy
Grand ma! Epilepsy/Last fit less than I month ago
Grand mal Epilepsy/Last fit more than I month ago
Petit ma! Epilepsy
Fits NOT Epilepsy

HAVE YOU EVER HAD JAUNDICE OR ANY LIVER DISEASE?
NO
Chronic liver disease
Congenital liver disease
Hepatic surgery
Jaundice
Nervous system disorder
Migraine
Multiple Sclerosis
Myasthenia Gravis
Mylagic Encephalomyelitis

                                                                                   Page5
                                                                                       out of 21

                                       EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
Other

HAVE YOU EVER HAD ANY DISEASES OR ILLNESSES OF THE RESPIRATORY SYSTEM?
NO
Asthma
Bronchitis
Pleurisy
Renal Disease
Renal Stones/Colic
Renal Surgery
Renal Transplant
Urinary Tract Infection (UTI)
Recurrent UTI
Other
Hypothyroidi sm/Con genital
Hypothyroidism in past
Hypothyroidism Current treatment
Thyrotoxicosis in past
Thyrotoxicosis/Current treatment
Thrombocytopenia
Other
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Other
Pneumonia
Respiratory disease
Tuberculosis in pastfrreated
Tuberculosis/Current treatment




                                                                                Page6
                                                                                    out of 21

                                  EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
                                        Page 4
HAVE YOU EVER HAD ANY DISEASES OR ILLNESSES OF THE DIGESTIVE TRACT?
NO
Bleeding PR
Cholecystitis
Consti pati on
Coeliac Disease
Crohn’s Disease
Fibrocytic disease of the pancreas

ARE YOU ALLERGIC TO ANYTHING THAT YOU KNOW OF?
NO
Antibiotics
Aspirin
Other drug allergy

HAVE YOU EVER HAD GERMAN MEASLES OR CHICKENPOX
NO
Chickenpox/Past infection
Chickenpoxflnfection this pregnancy
Chickenpox/Recent contact
Unsure about Chickenpox
Rubella vaccinationfprior to pregnancy
Rubella Vaccination/During this pregnancy
Rubellafpast infection
Rubellaflnfection this pregnancy
Rubella/Recent contact
Unsure about Rubella

HAVE YOU EVER HAD AN OPERATION? (EXCLUDING TOP, ,ECTOPIC, D&C ETC)
NO
Appendectomy
Breast biopsy
Cholecystectomy
Facial surgery
Laparotomy

HAVE YOU HAD ANY ORTHOPAEDIC PROBLEMS?
NO
Arthritis
Back problems
Congenital Dislocation of the Hips
Fracture
Fractured pelvis

HAVE YOU EVER HAD ANY SERIOUS INFECTIONS?
NO
Cytome galovirus
Glandular Fever
Malaria

                                                                               Page7
                                                                                   out of 21

                                   EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
Gastro-intestinal disease
Gastric/Duodenal ulcer
Haemorrhoids/Not treated
Haemorrhoids/Treated
Hiatus Hernia
Recurrent Diarrhoea
Ulcerative Colitis
Plaster
Latex
Other allergy
Mammop lasty
Mastectomy
Repair cleft lipkleft palate
Sp lenectomy
Tonsillectomy/ Addenoidectomy
Other
Jaw problems
Orthopaedic surgery
Scoliosis
Spina Bifida
Spinal surgery
Other
Polio
Toxoplasmosis
Tropical disease
Other




                                                                              Page8
                                                                                  out of 21

                                EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
                                      Page 5
HAVE YOU EVER HAD ANY EMOTIONAL/PSYCHOLOGICAL PROBLEMS?
NO
Anorexia Nervosa
Bulimia Nervosa
Depression/In past
Depression/Now
Nervous breakdown
THIS IS CONFIDENTIAL INFORMATION
HAVE YOU EVER RECEIVED MEDICAL HELP FOR EM OTIONAL/PSYCHOLOGICAL PROBLEMS?
PMT /Severe
Postnatal Depression
Puerperal Psychosis
Schizophrenia
Self harm
Suicide attempt
Other
NO
Treatment/GP
Treatment/Psychiatric outpatient
Treatment/Psychiatric inpatient

HAVE YOU EVER HAD GYNAECOLOGICAL PROBLEMS OR OPERATIONS?
NO
Abnormal cervical smears
Col poscopy
Cone biopsy
Congenital Uterine abnormality
D&C/Not after miscarriage
Endometriosis
Fibroids
Pelvic floor repair
Reversal of sterilisation
S teril isation
Surgery to abnormal uterus

WHEN WAS YOUR LAST CERVICAL SMEAR?
Within last three years
Longer than three years

WHAT WAS THE RESULT OF YOUR LAST SMEAR?
Normal
Warty change
Inflammatory changes
Awaiting result/PLEASE CHECK
NO
Candida Albicans
Chlamydia
Genital warts

                                                                             Page9
                                                                                 out of 21

                                 EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
Gonorrhoea
Herpes Genitalis
Infertility investigations
Laparoscopy
Laparotomy
Laser treatment
Loop excision
Myornectomy
Ovarian cyst
Pelvic Inflammatory Disease
Treatment for genital warts
Tubal surgery
Urinary incontinence
Other
Smear never performed

HAVE YOU EVER HAD ANY VAGINAL INFECTIONS OR SEXUALLY TRANSMITTED DISEASES?
Counselling
Other
THIS IS CONFIDENTIAL INFORMATION
Go to 1.24
CIN I
CIN II
IN III
Other
HIV Test positive
Non Specific Urethritis
Syphilis
Trichmonas Vaginalis
Vagini tis
Other
THIS IS CONFIDENTIAL INFORMATION




                                                                                Page10 of 21
                                                                                    out

                                  EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
                                         Page 6
Anaemia/ln pregnancy
Anaemia/Not in pregnancy
HAVE YOU EVER BEEN TREATED FOR ANAEMIA OR A BLOOD DISORDER?

HAVE YOU EVER HAD A BLOOD TRANSFUSION?
N0
Blood transfusion UK/No problems
Blood transfusion UK/REACTION

HAVE YOU EVER SMOKED?
WERE YOU A SMOKER AT TIME OF CONCEPTION?
opped less than 12 months before conception
opped more than 12 months before conception

HOW MANY CIGARETTES DO YOU SMOKE NOW?
Stopped
Occasional
5 a day
ever drinks alcohol
Occasionally
ever drinks alcohol
ccasi onally
5
9
1.32 HAVE YOU GOT ANY TATTOOS OR BODY PIERCING?

Go to 1.30
0ccasionally
Thalassaemia Minor
Sickle Cell Trait
Sickle Cell Disease
Other
Blood transfusion abroad/No problems
Blood transfusion abroad/REACTION
Don’t know
Yes
Yes
6-
10 a day
I 1-20 a day
More than 20 a day
HOW OFTEN DID YOU DRINK ALCOHOL BEFORE YOU BECAME PREGNANT? (UNITS PER WEEK)
10- 14
I 5- 20
More than 20
5
9

OW MUCH ALCOHOL DO YOU DRINK NOW? (UNITS PER WEEK)

                                                                                Page11 of 21
                                                                                    out

                                    EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
10- 14
I 5- 20
More than 20
B
ody piercing
Tattoos
AVE YOU HAD ANY TABLETS, MEDICINES OR INJECTIONS THIS PREGNANCY?

Si
Yes




                                                                                Page12 of 21
                                                                                    out

                                  EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
                                        Page 7
1.34
1.35
1.36
1.37
WHAT HAVE YOU TAKEN?
Antacids
Antibiotics
Anticoagulan ts
Antidepressants
Antiernetics
Anti epileptic
An tihistimi nes
Antihypertensi ves
Laxatives
Oral Antidiabetics
Pain Killers
Folic Acid
Herbal preparations
Homeopathic drugs
Hormone treatment
Immunoglobulins
Insulin
Inhalers
Iron tablets
Sleeping tablets
Steroids/Anti inflammatory drugs
Thyroid treatment
Other

FOR WHAT REASON WERE THE TABLETS, MEDICINES OR INJECTIONS GIVEN?

Allergies/Hayfever
Anaemia
Asthma
Blood clotting problems
Constipation
Depress ion
Diabetes
Epilepsy
Headaches

HAVE YOU EVER TAKEN RECREATIONAL DRUGS?

NO
Amphetamines
Barbiturates/IV
Barbiturates/Orally
Cannabis
Cocaine

                                                                               Page13 of 21
                                                                                   out

                                   EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
Diazepam
Ecstacy
THIS IS CONFIDENTIAL INFORMATION

DO YOU TAKE RECREATIONAL DRUGS NOW?

NO
Amphetamines
B arbiturates/IV
Barbiturates/Orally
Can nab is
Cocaine
Diazeparn
Ecstacy
THIS IS CONFIDENTIAL INFORMATION
Go to 1.38
Go to 1.38
Heart disease
Heart burnfl ndi gestion
Infection
Insomni a
Morning sickness
Pain
Prophylactic
Thyroid problem
Other
Heroi n/IV
Heroin/S moked
LSD
Methadone/IV
Methadone/Orally
Temazepam/IV
Temazepam/Orally
Tranquillisers
Other
Heroin/IV
Herion/Smoked
LSD
Methadone/IV
Methadone/Orally
Temazepam/IV
Temazepam/Ora1ly
Tranquillisers
Other




                                                                                 Page14 of 21
                                                                                     out

                                   EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
                                         Page 8
1.38 HAVE YOU EVER RECEIVED MEDICAL HELP FOR ALCOHOL OR DRUGS PROBLEMS?

Counselling
Drug abuse clinic
Other
THIS IS CONFIDENTIAL INFORMATION
NO
Treatmen t/GP
Treatmentjpsychiatric outpatient
Treatment/Psychiatric in patient

.39 HAVE YOU A FAMILY HISTORY OF HYPERTENSION?
NO
Own mother in pregnancy
Partner’s mother in pregnancy

.40 HAVE YOU A FAMILY HISTORY OF HEART PROBLEMS?
NO
Angina
Heart attack
High cholesterol

.41 HAVE YOU A FAMILY HISTORY OF THYROID DISEASE?
NO
Yes

.42 HAVE YOU A FAMILY HISTORY OF DIABETES? (YOUR FAMILY ONLY)
Adopted (family history not known)
Other family history of hypertension
Stroke
Not known
Other
Not known
NO
Yes

.43 HAVE YOU A FAMILY HISTORY OF ANY BLOOD DISORDERS?

Not known
NO
Christmas Disease
DVT
Haemophilia
Pulmonary embolus
Sickle Cell Trait
Sickle Cell Disease

.44 DO YOU HAVE A FAMILY HISTORY OF OTHER DISORDERS?
NO

                                                                                Page15 of 21
                                                                                    out

                                    EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
Familial Hypercholesterolaemia
Huntingdon’s Chorea
Thalassaemia Minor
Thalassaemia
Thrombosis
Von Willibrands Disease
Not Known
Other
Go to 1.46
Mental retardation
Other genetidfamily disorders




                                                                               Page16 of 21
                                                                                   out

                                 EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
                                          Page 9
us
1.46
1.47
2.1
2.2
23
2.4
HAVE ANY OF YOUR FAMILY GIVEN BIRTH TO A BABY THAT HAS NOT BEEN NORMAL?

NO
Anencephaly
B I ind ness
Cardiac abnormality
Cerebral Palsy
Chromosomal abnormality
Cleft lip
Cleft palate
Muscular dystrophy
Pheny lketonuria
Not known
HAVE YOU A FAMILY HISTORY OF DEPRESSION OR ANXIETY?

NO
Yes
NO
NO
Yes

HAVE YOU A RECENT FAMILY HISTORY OF TUBERCULOSIS? (LAST 5 YEARS)
Not known
NO
HAVE YOU EVER BEEN PREGNANT BEFORE? (INCLUDE TOP, MISCARRIAGES, ECTOPICS ETC)
Go to 8. I
Deliveries after 37 weeks
Deliveries before 37 weeks
Ectopic pregnancies
Not known
Yes
Yes
ARE ANY OF YOUR PREGNANCIES WITH A DIFFERENT PARTNER?

Congenital Dislocation of the Hips
Cystic Fibrosis
Deafness
Down’s Syndrome
Extra digits
Hydrocephaly
Hypothyro idism
Microcephaly

                                                                                 Page17 of 21
                                                                                     out

                                     EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
Skeletal abnormality
Spina Bifida
Other
Hydatidiform (Molar) pregnancies
Miscarriages
Termination of pregnancies
1
•
•
HOW MANY TIMES HAVE YOU BEEN PREGNANT INCLUDING THIS PREGNANCY?
Number of pregnancies

PLEASE INDICATE HOW MANY OF THE FOLLOWING YOU HAVE HAD

Page 10

8
.1 WHO DO YOU LIVE WITH?
Husband
Partner
Parents
Parents-in- law
Relati ves

8. 2 WAS THIS A PLANNED PREGNANCY?
Planned pregnancy

8.3 DID THIS PREGNANCY RESULT FROM A COURSE OF TREATMENT?
No
Artificial insemination (Husband)
Artificial insemination (Donor)
Became pregnant during investigations
Bromocriptine
Clomiphene
GIFT
8
8
Less than I year
1-2 years
2- 3 years
NO
Cap
Coil in situ
Combined pill
Condoms
Depo Provera injections
Female sterilisation

8.6 HAVE YOU EVER SOUGHT CONTRACEPTIVE ADVICE?
Ad vertisements/Pu blicati ons/Magazines
BASE
Brooke Advisory Service
                                                                                         Page18 of 21
                                                                                             out

                                           EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
BYPASS
Family Planning Clinic
Friends
GAP
GP
School Nurse
St Luke’s Centre
TeachersI
In care
Lives alone
Sheltered accommodationkefuge
Other
Unplanned pregnancy
Human Chorionic Gonadotrophin
Intrauterine insemination
VF
Pregonal/Metrodin
Reversal of sterilisation
Tuba! surgery
Other

4 HOW LONG HAVE YOU BEEN TRYING TO GET PREGNANT?
Friends
Homeless
3-4 years
4-5 years
More than 5 years

5 DID YOU BECOME PREGNANT WHILE USING CONTRACEPTION?
Implants
Internet
LIFE
Parents/Guardians/Relatives
Pharmacist
Practice Nurse
Sex education in school
No/Did not know where to go for advice
No/But knew where to get advice
Other
Go to 8.5
Morning after pill
Progesterone only pill
Rhythm method
Spermicides
Vasectomy
Withdrawal
Health Visitor
Healthwise




                                                                                     Page19 of 21
                                                                                         out

                                         EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
                                      Page 11

WHAI ••••1l••S REGARDING THIS PREGNANCY?

FIRST DAY OF YOUR LAST MENSTRUAL PERIOD?
Unsure
No
Alphafeto Protein
Amniocentesis
Chronic Villus Sampling
Chromosome Studies
N one
Backache
Breast tenderness
Constipation
Frequency of micturition
Headaches
Insomnia

WHAT TYPE OF DIET DO YOU EAT?
Conventional (meat and vegetables)
Coeliac
Diabetic
Reducing
No red meat
EVER HAD ANY BLEEDING DURING THIS PREGNANCY?
Unsure
WHAT SYMPTOMS HAVE YOU EXPERIENCED DURING THIS PREGNANCY?
Yes/Painless
Yes/Painful
HAVE YOU HAD ANY SPECIAL TESTS/INVESTIGATIONS DURING THIS PREGNANCY?

HAVE YOU ANY THOUGHTS ON HOW YOU WOULD LIKE TO FEED YOUR BABY?
Breast
Breast and bottle
WHAT TYPE OF ANTENATAL PREPARATION CLASS WOULD LIKE TO ATTEND?
Not required
Parentcraft classes
Increased vaginal discharge
Nausea1Moming sickness
Nose bleeds
Tiredness
Weepy ness
Other
Bottle
Undecided
Tour only
Aquanatal
Cordocentesis
Nuchal Translucency Scan
Serial Scans
                                                                                Page20 of 21
                                                                                    out

                                  EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)
Triple Test
Other
Vegetarian
Vegan
Food safety/Dietary Advice given
Referred to Dietician
Other




                                                                               Page21 of 21
                                                                                   out

                                   EEPDPCFILES/16_QUESTIONS/aINITIAL/Bolton-2.doc (26 Sept 08)

								
To top