Termination of pregnancy self referral form

Forename: *

Surname *

Title

Date of birth *

Community Health Index (CHI): if known

Address *

Postcode *

Mobile number *

Email address *

Password *

Preferred mode of contact *

Phone/text

Email

GP name and practice address

What is your first language?

Do you require an interpreter?

Do you identify with a gender different to that assigned at birth?

Current pregnancy

Date of first day of last period

If you have entered a date above, are you certain of this date?

Yes

No

Date of positive pregnancy test *

In your current pregnancy, did you become pregnant while on contraception ie oral tablet, coil, implant etc?

Yes

No

If you answered yes to above, what contraception were you taking?

Have you taken any emergency contraception (for example the "morning after pill"), if yes when did you take this?

Medical history

Medication you are taking *

Allergies *

Further information

Press submit to send referral, this will allow us to arrange an appointment to discuss your options.

Pregnancy history

Have you been pregnant before? *

Yes

No

No. of previous pregnancies

Date of last pregnancy

Number of live births

Other pregnancy outcomes

Previous Caesarean Sections

History of complications

Weather warning

Termination of pregnancy self referral form

Current pregnancy

Pregnancy history

NHS Fife

Contact

Social

Terms