1.  I have a long-term health condition that may affect my pregnancy. I have:

• diabetes
• epilepsy
• mental health problems
• high blood pressure
• heart problems
• asthma
• hypo/hyperthyroidism
• other
• none.

2. Bladder and bowel problems are common and can get worse in pregnancy. Support is available. Please discuss with your GP, midwife or doctor if you experience any of the following:

• leakage of urine
• problems holding wind (gas)
• unable to control the loss of stool (poo)
• bleeding from the back passage
• pain or bleeding during or after sex (intercourse)
• affected by Female Genital Mutilation (FGM)

3. It is recommended that you discuss pre-existing medical conditions and/or special requirements with your GP, midwife or doctor prior to becoming pregnant or in early pregnancy. Tick the comment that applies to you:

• I have discussed my pre-existing medical condition(s) with my maternity team
• I require further support with my medical condition(s) or special needs
• I am aware that in certain circumstances my midwife or health care professional may need to communicate with my GP or health visitor
• I am not sure/I would like to find out more.

4. I am taking the following medication and/or supplements. Tick the comment that applies to you:

• I am aware of the recommendations and I have discussed this with my GP, doctor or midwife
• I am not sure/I would like to find out more.

5. I have additional requirements. These are:

• I will need help at appointments to translate into my language
• I have allergies and/or special dietary requirements
• I have religious beliefs and customs that I would like to be observed
• I/my partner have additional needs
• I have a current or previous history of social care involvement
• I would like to speak to the midwife about something else in a private setting

6. It is recommended that you avoid some foods whilst pregnant, as they can cause harm to you and your unborn baby. Tick the comment that applies to you:

• I am aware of what foods to avoid in pregnancy
• I am not sure/I would like to find out more.

7. It is recommended that you try to maintain a healthy and balanced diet in pregnancy. Tick the comment that applies to you:

• I am aware of my nutritional needs in pregnancy
• I have specific circumstances that affect my dietary requirements and I would like guidance from my maternity team
• I am not sure/I would like to find out more.

8. For the majority of women, regular light to moderate exercise is recommended in pregnancy. Tick the comment that applies to you:

• I am aware of the recommendations about exercise
• I have a condition that affects my ability to exercise and I would like guidance from my maternity team
• I am not sure/I would like to find out more.

9. For the health and wellbeing of you and your baby, you are advised not to smoke, drink alcohol or use recreational drugs in pregnancy. Tick the comment that applies to you:

• I am aware of advice around the consumption of alcohol, tobacco/nicotine products and recreational/illegal drugs
• I am aware that smoking increases the chances of having a miscarriage and increases the risk of having a baby born too early, underweight or stillborn
• I am aware that all pregnant women are offered carbon monoxide screening during pregnancy and support to quit for those who smoke
• I am not sure/I would like to find out more

10. I have a long term mental health condition that may affect my pregnancy. I have:

• anxiety
• depression
• eating disorder
• post-traumatic stress disorder
• personality disorder
• bipolar affective disorder (also known as manic depression or mania)
• schizoaffective disorder
• schizophrenia or any other psychotic illness
• postpartum psychosis
• any other mental health condition for which you have seen a psychiatrist or other mental health professional.

11. This is how I’m feeling at the moment.

12. Getting to know your baby during pregnancy helps to build strong parental relationships, and will also help with your emotional wellbeing. You can try the following:

• talking, singing or playing music to your unborn baby
• gently massaging your bump
• writing a journal
• pregnancy yoga and/or hypnobirthing
• using an app to track your baby’s growth and development
• reading UNICEF’s ‘Building a happy baby guide’.

13. I am aware of things I can do to enhance my emotional wellbeing. Tick the comment that will help you the most:

• take regular gentle exercise, such as pregnancy yoga, walking or swimming
• ensure I eat well
• try relaxation techniques, listening to music, meditation or breathing exercises
• take time for myself, somewhere I can relax
• talk to someone I trust – friend, family, midwife, GP or doctor
• ask for practical help with household chores or other children.

14. Specialist support for pregnant women with anxiety and depression or any other mental health condition is available. Tick the comment that applies to you:

• I am aware of how to access mental health support if I need it whilst pregnant
• I am not sure/I would like to find out more.

15. Emotions my partner, family and I should look out for include:

• tearfulness
• feeling overwhelmed
• feeling irritable or arguing more often
• difficulty concentrating
• change in appetite
• problems sleeping or extreme energy
• feeling very anxious
• racing thoughts
• loss of interest in things I normally like
• being so afraid of birth that I don’t want to go through with it
• having unpleasant thoughts that I can’t control or keep coming back
• suicidal feelings or thoughts of self-harm
• repeating actions or developing strict rituals
• lack of feeling towards my unborn baby.

16. Thinking about contraceptive choices. Tick the comment that applies to you:

• I am not sure what to choose/I would like to find out more
• I would like to wait until after my baby is born to think about this
• I am aware that immediate postnatal contraception is available after my baby is born. My choice is stated in the box below.