Hospital Number: 
Surname: 
Date of Birth: 

Question Text: Have you had any cardiac problems?
Question ID: 275
Question Summary: Cardiac Problems
Table Name: Patient
Field Name: CardiacProblem
Answer ID:1970     [ ]  No
Answer ID:7874     [ ]  Arrhythmia
Answer ID:18028     [ ]  Cardiac disease (under cardiac care)_________________
Answer ID:18029     [ ]  Cardiac murmur (under cardiac care)
Answer ID:1972     [ ]  Cardiac murmur
Answer ID:11202     [ ]  Cardiac surgery_________________
Answer ID:11203     [ ]  Cardiac transplant
Answer ID:12966     [ ]  Congenital cardiac anomaly_________________
Answer ID:17587     [ ]  Ischaemic heart disease_________________
Answer ID:1971     [ ]  Rheumatic fever
Answer ID:1973     [ ]  Valve lesion
Answer ID:1980     [ ]  Other_________________

Question Text: Have you ever had hypertension?
Question ID: 2622
Question Summary: Hypertension
Table Name: Patient
Field Name: Hypertension
Answer ID:17350     [ ]  No
Answer ID:18058     [ ]  Currently - medicated_________________
Answer ID:18059     [ ]  Currently - no medication
Answer ID:17351     [ ]  During pregnancy medicated_________________
Answer ID:17352     [ ]  During pregnancy not medicated
Answer ID:17353     [ ]  Non pregnant medicated
Answer ID:17354     [ ]  Non pregnant no medication

Question Text: Have you had anaemia or other haematological problems?
Question ID: 277
Question Summary: Haematological Problems
Table Name: Patient
Field Name: HaematologicalProblem
Answer ID:8784     [ ]  No
Answer ID:6934     [ ]  Anaemia
Answer ID:17318     [ ]  Antibody sensitivity_________________
Answer ID:6939     [ ]  Alpha Thalassaemia
Answer ID:6938     [ ]  Beta Thalassaemia
Answer ID:17588     [ ]  Beta Thalassaemia Trait
Answer ID:18045     [ ]  Bone marrow transplant
Answer ID:17320     [ ]  Rhesus isoimmunisation
Answer ID:6937     [ ]  Sickle cell disease
Answer ID:6936     [ ]  Sickle cell trait
Answer ID:1998     [ ]  Other_________________

Question Text: Is there any history of thromboembolic or clotting disorders?
Question ID: 2623
Question Summary: Thromboembolic Disorder
Table Name: Patient
Field Name: ThromboembolicDisorder
Answer ID:17356     [ ]  No
Answer ID:17357     [ ]  Antiphospholipid syndrome
Answer ID:18031     [ ]  Antithrombin deficiency
Answer ID:18183     [ ]  Compound heterozygotes
Answer ID:17358     [ ]  DVT - anticoagulated
Answer ID:17359     [ ]  DVT - not anticoagulated
Answer ID:18030     [ ]  Factor V Leiden (homozygous)
Answer ID:18074     [ ]  Haemophilia
Answer ID:18037     [ ]  Idiopathic Thrombocytopenic Purpura (ITP)
Answer ID:18038     [ ]  Previous arterial thrombosis
Answer ID:17361     [ ]  Previous DIC
Answer ID:17362     [ ]  Protein C deficiency
Answer ID:17363     [ ]  Protein S deficiency
Answer ID:18033     [ ]  Prothrombin mutation (factor II homozygous)
Answer ID:17364     [ ]  Pulmonary embolus
Answer ID:17365     [ ]  Thrombocytopenia
Answer ID:17366     [ ]  Thrombophilia
Answer ID:17367     [ ]  Varicose veins with phlebitis
Answer ID:17368     [ ]  Varicose veins no phlebitis
Answer ID:17369     [ ]  Von Willebrand disease
Answer ID:17370     [ ]  Other_________________

Question Text: Have you had any respiratory problems?
Question ID: 282
Question Summary: Respiratory Problems
Table Name: Patient
Field Name: RespiratoryProblem
Answer ID:2044     [ ]  No
Answer ID:9080     [ ]  Asthma
Answer ID:18060     [ ]  Asthma - previous admission in last 12 months
Answer ID:18061     [ ]  Asthma - Specialist Consultant Care
Answer ID:2050     [ ]  Chronic bronchitis
Answer ID:18064     [ ]  Chronic obstructive airway disease
Answer ID:16744     [ ]  Cystic fibrosis
Answer ID:6917     [ ]  Hay fever
Answer ID:18063     [ ]  Pulmonary fibrosis
Answer ID:18062     [ ]  Sarcoidosis
Answer ID:2048     [ ]  Tuberculosis CURRENT treatment_________________
Answer ID:2047     [ ]  Tuberculosis past treatment
Answer ID:2051     [ ]  Other_________________

Question Text: Have you had jaundice or liver problems?
Question ID: 281
Question Summary: Hepatic Problems
Table Name: Patient
Field Name: HepaticProblems
Answer ID:2038     [ ]  No
Answer ID:17589     [ ]  Acute Fatty Liver_________________
Answer ID:18076     [ ]  Autoimmune hepatitis
Answer ID:17590     [ ]  HELLP syndrome
Answer ID:2042     [ ]  Hepatitis A_________________
Answer ID:6921     [ ]  Hepatitis B_________________
Answer ID:6922     [ ]  Hepatitis C_________________
Answer ID:6923     [ ]  Hepatitis type unknown
Answer ID:2040     [ ]  Jaundice not hepatitis specific_________________
Answer ID:6984     [ ]  Liver transplant
Answer ID:6924     [ ]  Obstetric cholestasis
Answer ID:2043     [ ]  Other hepatic problem_________________

Question Text: Have you had urinary or kidney problems?
Question ID: 1640
Question Summary: Renal Problems
Table Name: Patient
Field Name: RenalProblems
Answer ID:11224     [ ]  No
Answer ID:18015     [ ]  Chronic renal failure
Answer ID:11229     [ ]  Congenital renal anomaly_________________
Answer ID:18016     [ ]  Dysplasia
Answer ID:18017     [ ]  Glomerulonephritis
Answer ID:18018     [ ]  Glomerulosclorosis
Answer ID:18019     [ ]  Haemolytic uremic syndrome
Answer ID:18020     [ ]  Henoch-Schonlein Purpura
Answer ID:18021     [ ]  IgA Nephropathy
Answer ID:18022     [ ]  Lupus Nephritis
Answer ID:11233     [ ]  Nephrectomy
Answer ID:18023     [ ]  Nephrotic Syndrome
Answer ID:17591     [ ]  Polycystic kidney disease
Answer ID:11226     [ ]  Pyelonephritis
Answer ID:11225     [ ]  Recurrent infection
Answer ID:11228     [ ]  Renal stones or colic
Answer ID:11236     [ ]  Renal surgery_________________
Answer ID:11234     [ ]  Renal transplant
Answer ID:11227     [ ]  Urinary incontinence
Answer ID:11237     [ ]  Other renal_________________

Question Text: Have you had any gastrointestinal problems?
Question ID: 283
Question Summary: Gastrointestinal Problems
Table Name: Patient
Field Name: GastroIntestinalProblem
Answer ID:2052     [ ]  No
Answer ID:18067     [ ]  Achalasia
Answer ID:2061     [ ]  Coeliac disease
Answer ID:2059     [ ]  Crohns disease
Answer ID:6920     [ ]  Faecal incontinence
Answer ID:2053     [ ]  Haemorrhoids treated
Answer ID:2054     [ ]  Haemorrhoids not treated
Answer ID:6919     [ ]  Hiatus hernia
Answer ID:2063     [ ]  Irritable bowel syndrome
Answer ID:18066     [ ]  Gastric ulcer
Answer ID:18065     [ ]  Malabsorption syndrome
Answer ID:2062     [ ]  Pancreatitis
Answer ID:2060     [ ]  Ulcerative colitis
Answer ID:2066     [ ]  Other_________________

Question Text: Have you had any endocrine problems?
Question ID: 279
Question Summary: Endocrine Problems
Table Name: Patient
Field Name: EndocrineProblem
Answer ID:2013     [ ]  No
Answer ID:18024     [ ]  Addisons disease
Answer ID:18025     [ ]  Autoimmune hypothyroidism
Answer ID:18026     [ ]  Cushings syndrome
Answer ID:11139     [ ]  Diabetes type 1
Answer ID:2016     [ ]  Diabetes type 2
Answer ID:18027     [ ]  Endocrine disease_________________
Answer ID:2017     [ ]  Gestational diabetes
Answer ID:2019     [ ]  Hyperthyroidism
Answer ID:17592     [ ]  Hyperthyroidism - current_________________
Answer ID:17593     [ ]  Hyperthyroidism in past
Answer ID:2022     [ ]  Hypothyroidism
Answer ID:16745     [ ]  Pituitary disorder_________________
Answer ID:11354     [ ]  Polycystic ovarian syndrome (PCOS)
Answer ID:2025     [ ]  Other_________________

Question Text: Are there any diabetic concerns?
Question ID: 2494
Question Summary: Diabetic Concerns
Table Name: Pregnancy
Field Name: DiabeticCoMorbidities
Answer ID:16625     [ ]  None
Answer ID:16626     [ ]  Diabetic retinopathy_________________
Answer ID:16627     [ ]  Diabetic nephropathy_________________
Answer ID:16628     [ ]  Autonomic neuropathy_________________
Answer ID:16629     [ ]  Fluctuating glycaemic control_________________
Answer ID:16630     [ ]  Other_________________

Question Text: How is the diabetes controlled?
Question ID: 1011
Question Summary: Diabetes Control
Table Name: Patient
Field Name: DiabeticControl
Answer ID:7431     [ ]  Diet & exercise
Answer ID:7433     [ ]  Insulin
Answer ID:7432     [ ]  Oral hypoglycaemics

Question Text: What is the latest HbA1c result? (%)
Question ID: 2485
Question Summary: Latest HbA1c
Table Name: Pregnancy
Field Name: ResultHbA1c
___________________________________
Answer ID:16607     [ ]  Not known

Question Text: Has retinal assessment been performed in the last 12 months?
Question ID: 2488
Question Summary: Retinal Assessment
Table Name: Pregnancy
Field Name: RetinopathyScreening
Answer ID:16631     [ ]  Yes
Answer ID:16632     [ ]  No

Question Text: Has a renal assessment been undertaken in the last 12 months?
Question ID: 2493
Question Summary: Renal Assessment
Table Name: Pregnancy
Field Name: RenalAssessment
Answer ID:16622     [ ]  Yes
Answer ID:16623     [ ]  No

Question Text: Did you have any preconceptual counselling?
Question ID: 1220
Question Summary: Preconceptual Counselling
Table Name: Pregnancy
Field Name: PreconceptualCounselling
Answer ID:8312     [ ]  No
Answer ID:8311     [ ]  Yes

Question Text: Have you had fits, epilepsy or neurological problems?
Question ID: 280
Question Summary: Neurological Problems
Table Name: Patient
Field Name: NeurologicalProblem
Answer ID:2026     [ ]  No
Answer ID:18039     [ ]  Cerebral palsy
Answer ID:2035     [ ]  Chronic fatigue syndrome
Answer ID:2036     [ ]  Epilepsy no medication
Answer ID:2028     [ ]  Epilepsy requires medication_________________
Answer ID:16765     [ ]  Fits Not epilepsy_________________
Answer ID:2030     [ ]  Migraine
Answer ID:18040     [ ]  Migraine - severe
Answer ID:18041     [ ]  Myotonic dystrophy
Answer ID:18042     [ ]  Neuropathy
Answer ID:18043     [ ]  Previous subarachnoid haemorrhage
Answer ID:6925     [ ]  Spina bifida
Answer ID:18044     [ ]  Stroke
Answer ID:2037     [ ]  Other_________________

Question Text: Do you have any of the following inherited disorders?
Question ID: 2621
Question Summary: Genetic/Inherited Disorder
Table Name: Patient
Field Name: GeneticDisorder
Answer ID:17336     [ ]  No
Answer ID:17337     [ ]  Aperts Syndrome
Answer ID:17338     [ ]  Congenital adrenal hyperplasia
Answer ID:17339     [ ]  Congenital hip dysplasia
Answer ID:17340     [ ]  Cystic fibrosis
Answer ID:17341     [ ]  Down's Syndrome
Answer ID:17342     [ ]  Haemochromatosis
Answer ID:17343     [ ]  Klinefelters Syndrome
Answer ID:17344     [ ]  Marfans Syndrome
Answer ID:17345     [ ]  MCADD
Answer ID:17346     [ ]  Muscular dystrophy
Answer ID:17347     [ ]  Neurofibromatosis
Answer ID:17348     [ ]  Phenylketonuria
Answer ID:17349     [ ]  Other_________________

Question Text: Are you receiving specialist secondary care because of this genetic condition?
Question ID: 2723
Question Summary: Specialist Care
Table Name: Pregnancy
Field Name: GeneticDisorderSpecialistInput
Answer ID:18048     [ ]  No
Answer ID:18049     [ ]  Yes

Question Text: Is there any history of autoimmune disease?
Question ID: 2619
Question Summary: Autoimmune Disease
Table Name: Patient
Field Name: AutoImmuneDisease
Answer ID:17321     [ ]  No
Answer ID:17323     [ ]  Gestational pemphigoid
Answer ID:17324     [ ]  Multiple sclerosis
Answer ID:17325     [ ]  Myasthenia Gravis_________________
Answer ID:17326     [ ]  Pernicious anaemia_________________
Answer ID:17327     [ ]  Psoriasis
Answer ID:18034     [ ]  Psoriatic arthropathy
Answer ID:17328     [ ]  Rheumatoid arthritis
Answer ID:17329     [ ]  Systemic lupus erythematosus
Answer ID:18035     [ ]  Systemic sclerosis
Answer ID:17330     [ ]  Vitiligo
Answer ID:17331     [ ]  Other_________________

Question Text: Have you had any skin problems?
Question ID: 285
Question Summary: Dermatological Problems
Table Name: Patient
Field Name: DermatalogicalProblem
Answer ID:2075     [ ]  No
Answer ID:2079     [ ]  Acne
Answer ID:6928     [ ]  Contact dermatitis
Answer ID:2077     [ ]  Eczema
Answer ID:11357     [ ]  Melanoma
Answer ID:2076     [ ]  Psoriasis
Answer ID:2078     [ ]  Other_________________

Question Text: Is there any possibility that you have taken roaccutane (Isotretinoin) in early pregnancy?
Question ID: 1639
Question Summary: Roaccutane
Table Name: Pregnancy
Field Name: Roaccutane
Answer ID:11238     [ ]  No
Answer ID:11223     [ ]  Yes_________________

Question Text: Have you had any musculoskeletal problems?
Question ID: 1221
Question Summary: Musculoskeletal Problems
Table Name: Patient
Field Name: MusculoskeletalProblem
Answer ID:8454     [ ]  No
Answer ID:17371     [ ]  Achondroplasia
Answer ID:18077     [ ]  Achondroplasia - Specialist consultant care
Answer ID:8316     [ ]  Connective tissue disorder
Answer ID:8313     [ ]  Fractured pelvis
Answer ID:8377     [ ]  Scoliosis
Answer ID:16526     [ ]  Spinal injury_________________
Answer ID:16525     [ ]  Syphysis pubis dysfunction
Answer ID:8317     [ ]  Other_________________

Question Text: Is there any history of malignancy within the last 3 years?
Question ID: 1904
Question Summary: Malignancy
Table Name: Patient
Field Name: Malignancy
Answer ID:13101     [ ]  No
Answer ID:13102     [ ]  Treatment in past 3 yrs_________________
Answer ID:13103     [ ]  Current treatment_________________

Question Text: Have you had any gynaecological problems or surgery?
Question ID: 288
Question Summary: Gynaecological  Problems or Surgery
Table Name: Patient
Field Name: GynaecologicalProb
Answer ID:2103     [ ]  No
Answer ID:2113     [ ]  Abnormal cervical smears
Answer ID:6930     [ ]  Cervical cautery
Answer ID:10182     [ ]  Colposcopy
Answer ID:2112     [ ]  Cone biopsy
Answer ID:2118     [ ]  D and C NOT after miscarriage
Answer ID:18056     [ ]  Endometrial ablation
Answer ID:2117     [ ]  Endometriosis
Answer ID:2108     [ ]  Fibroids
Answer ID:2122     [ ]  Infertility investigations_________________
Answer ID:2105     [ ]  Laparotomy
Answer ID:2104     [ ]  Laparoscopy
Answer ID:2111     [ ]  Laser treatment
Answer ID:2106     [ ]  Myomectomy
Answer ID:2126     [ ]  Ovarian cystectomy_________________
Answer ID:2115     [ ]  Pelvic floor repair
Answer ID:2124     [ ]  Pelvic inflammatory disease
Answer ID:18132     [ ]  Previous OASIS repair
Answer ID:10181     [ ]  Reversal of sterilisation
Answer ID:18057     [ ]  Septectomy
Answer ID:2119     [ ]  Tubal surgery_________________
Answer ID:17594     [ ]  Uterine surgery_________________
Answer ID:2123     [ ]  Uterine anomaly_________________
Answer ID:6953     [ ]  Vulvo-vaginal warts
Answer ID:17595     [ ]  3 or more consecutive miscarriages
Answer ID:2125     [ ]  Other_________________

Question Text: Has the woman ever undergone female genital mutilation?
Question ID: 2649
Question Summary: Genital Mutilation
Table Name: Patient
Field Name: FGM
Answer ID:17596     [ ]  No
Answer ID:17597     [ ]  Yes

Question Text: What classification is the female genital mutilation?
Question ID: 2650
Question Summary: FGM Classification
Table Name: Pregnancy
Field Name: FGMClassification
Answer ID:17598     [ ]  Type 1
Answer ID:17599     [ ]  Type 2
Answer ID:17600     [ ]  Type 3
Answer ID:17601     [ ]  Type 4
Answer ID:17602     [ ]  Reversal already performed
Answer ID:17603     [ ]  Type not known

Question Text: Has a reversal been discussed?
Question ID: 2651
Question Summary: FGM Plan
Table Name: Pregnancy
Field Name: FGMReversal
Answer ID:17604     [ ]  No
Answer ID:17605     [ ]  Yes - obstetric referral required

Question Text: Has the woman ever been admitted to hospital?
Question ID: 2521
Question Summary: Previous Admissions
Table Name: Pregnancy
Field Name: AdmittedInPast
Answer ID:16759     [ ]  No
Answer ID:16760     [ ]  ICU_________________
Answer ID:16761     [ ]  HDU_________________
Answer ID:16762     [ ]  Accident and Emergency_________________
Answer ID:16763     [ ]  Other_________________

Question Text: When was your last smear?
Question ID: 289
Question Summary: Last Smear
Table Name: Pregnancy
Field Name: LastSmear
Answer ID:2127     [ ]  Smear never performed
Answer ID:10023     [ ]  Within last year
Answer ID:10024     [ ]  Within last two years
Answer ID:2130     [ ]  Within last three years
Answer ID:2131     [ ]  Over three years ago
Answer ID:2132     [ ]  Don't know

Question Text: What was the result of this smear?
Question ID: 290
Question Summary: Result of Last Smear
Table Name: Pregnancy
Field Name: ResultLastSmear
Answer ID:2133     [ ]  Normal
Answer ID:2136     [ ]  Awaiting result please check
Answer ID:2135     [ ]  Human papilloma virus
Answer ID:2134     [ ]  Inflammatory changes
Answer ID:2137     [ ]  Mild dyskaryosis or dysplasia
Answer ID:2138     [ ]  Moderate dyskaryosis or dysplasia
Answer ID:2139     [ ]  Severe dyskaryosis or dysplasia
Answer ID:2140     [ ]  Other_________________

Question Text: Is a postnatal smear required?
Question ID: 1222
Question Summary: Postnatal Smear Required
Table Name: Pregnancy
Field Name: PNSmearRequired
Answer ID:8461     [ ]  No
Answer ID:8462     [ ]  Yes

Question Text: Have you  had any other operations or surgery?
Question ID: 287
Question Summary: Operations
Table Name: Patient
Field Name: Operations
Answer ID:2091     [ ]  No
Answer ID:13668     [ ]  Appendicectomy
Answer ID:7875     [ ]  Breast augmentation
Answer ID:2095     [ ]  Breast biopsy
Answer ID:7876     [ ]  Breast reduction
Answer ID:15656     [ ]  Cholecstectomy
Answer ID:11358     [ ]  Hip surgery_________________
Answer ID:15657     [ ]  Laparotomy_________________
Answer ID:2096     [ ]  Mastectomy_________________
Answer ID:8308     [ ]  Spinal surgery_________________
Answer ID:2102     [ ]  Other_________________

Question Text: Have you had any infections?
Question ID: 284
Question Summary: Infections
Table Name: Patient
Field Name: Infections
Answer ID:2067     [ ]  No
Answer ID:6945     [ ]  Candida
Answer ID:13094     [ ]  C Difficile
Answer ID:6942     [ ]  Chicken pox
Answer ID:6946     [ ]  Chlamydia
Answer ID:2072     [ ]  Cytomegalovirus
Answer ID:6949     [ ]  Genital warts
Answer ID:2068     [ ]  Glandular fever
Answer ID:6940     [ ]  Group B strep colonisation
Answer ID:17606     [ ]  Gonorrhoea
Answer ID:6947     [ ]  Herpes genitalis
Answer ID:6952     [ ]  Human immunodifiency virus
Answer ID:2073     [ ]  Malaria
Answer ID:6943     [ ]  Meningitis
Answer ID:6948     [ ]  MRSA
Answer ID:7877     [ ]  Parvovirus
Answer ID:6951     [ ]  Polio
Answer ID:6941     [ ]  Rubella
Answer ID:6950     [ ]  Syphilis
Answer ID:2071     [ ]  Toxoplasmosis
Answer ID:2074     [ ]  Tropical disease_________________
Answer ID:2070     [ ]  Other_________________

Question Text: Have you had any mental health problems?
Question ID: 304
Question Summary: Mental Health Problems
Table Name: Patient
Field Name: MentalHealthProblem
Answer ID:2242     [ ]  No
Answer ID:7884     [ ]  Anxiety disorder
Answer ID:7878     [ ]  Bipolar disorder
Answer ID:2249     [ ]  Depression current treatment_________________
Answer ID:2243     [ ]  Depression past treatment_________________
Answer ID:7883     [ ]  Generalised anxiety disorder
Answer ID:17607     [ ]  Eating disorder_________________
Answer ID:10025     [ ]  Nervous breakdown_________________
Answer ID:6954     [ ]  Obsessive-compulsive disorder_________________
Answer ID:6956     [ ]  Overdose taken_________________
Answer ID:7882     [ ]  Post traumatic stress disorder
Answer ID:2254     [ ]  Previous postnatal depression_________________
Answer ID:2247     [ ]  Puerperal psychosis_________________
Answer ID:2245     [ ]  Schizophrenia
Answer ID:6955     [ ]  Self harm_________________
Answer ID:2244     [ ]  Suicide attempt_________________
Answer ID:2248     [ ]  Other_________________

Question Text: Are you currently receiving specialist secondary care because of this mental health issue?
Question ID: 2724
Question Summary: Secondary Care
Table Name: Pregnancy
Field Name: MentalHealthIssueSpecialistInput
Answer ID:18050     [ ]  No
Answer ID:18051     [ ]  Yes

Question Text: Have you had any mental health referrals or admissions?
Question ID: 1501
Question Summary: Mental Health Referrals or Admissions
Table Name: Pregnancy
Field Name: MedicalHelpPsych
Answer ID:10183     [ ]  No
Answer ID:10184     [ ]  Admission_________________
Answer ID:18052     [ ]  Detention under the Mental Health Act
Answer ID:10185     [ ]  Referral_________________
Answer ID:10186     [ ]  Other_________________

Question Text: Have you any physical disabilities?
Question ID: 274
Question Summary: Physical Disabilities
Table Name: Patient
Field Name: Impairments
Answer ID:1962     [ ]  No
Answer ID:1966     [ ]  Blind
Answer ID:17608     [ ]  Amputee_________________
Answer ID:1967     [ ]  Deaf with speech
Answer ID:1968     [ ]  Deaf without speech
Answer ID:18184     [ ]  Difficulty using arms
Answer ID:18055     [ ]  Impaired mobility (using crutches/frame)
Answer ID:17609     [ ]  Paralysis_________________
Answer ID:18054     [ ]  Partial hearing loss (severe)
Answer ID:18053     [ ]  Partially sighted (uncorrected by glasses)
Answer ID:1965     [ ]  Wheelchair user_________________
Answer ID:1969     [ ]  Other_________________

Question Text: Do you have any allergies?
Question ID: 306
Question Summary: Allergies
Table Name: Patient
Field Name: Allergies
Answer ID:2262     [ ]  No
Answer ID:2269     [ ]  Animals_________________
Answer ID:6959     [ ]  Aspirin_________________
Answer ID:10026     [ ]  Cosmetic or detergents_________________
Answer ID:6962     [ ]  Elastoplast_________________
Answer ID:2266     [ ]  Food/drinks_________________
Answer ID:2267     [ ]  Grass/pollen_________________
Answer ID:2270     [ ]  Latex_________________
Answer ID:6960     [ ]  Local anaesthetics_________________
Answer ID:11360     [ ]  Morphine_________________
Answer ID:2263     [ ]  Nuts_________________
Answer ID:6957     [ ]  Penicillin_________________
Answer ID:6958     [ ]  Septrin_________________
Answer ID:6961     [ ]  Scoline_________________
Answer ID:2264     [ ]  Other antibiotic_________________
Answer ID:2265     [ ]  Other_________________

Question Text: Have you had problems with previous anaesthetic?
Question ID: 1013
Question Summary: Past Anaesthetic Problems
Table Name: Patient
Field Name: PastAnaestheticProb
Answer ID:7436     [ ]  No
Answer ID:7438     [ ]  Problem with previous GA_________________
Answer ID:7437     [ ]  Problem with previous epidural_________________
Answer ID:13669     [ ]  Problem with previous spinal_________________

Question Text: Have you had a blood transfusion?
Question ID: 293
Question Summary: Blood Transfusions
Table Name: Patient
Field Name: BloodTransfusion
Answer ID:2161     [ ]  No
Answer ID:6963     [ ]  Yes
Answer ID:9087     [ ]  Declined blood products_________________
Answer ID:2166     [ ]  Not Known

Question Text: Did you have a transfusion reaction?
Question ID: 1012
Question Summary: Transfusion Reaction
Table Name: Patient
Field Name: TransfusionReaction
Answer ID:7435     [ ]  No
Answer ID:11222     [ ]  Yes_________________

Question Text: Have you any notable family history (state relationship and details)?
Question ID: 307
Question Summary: Family History of Note
Table Name: Pregnancy
Field Name: FHOfNote
Answer ID:2271     [ ]  No
Answer ID:6971     [ ]  Cardiac problem_________________
Answer ID:6972     [ ]  Clotting disorder_________________
Answer ID:17610     [ ]  Childhood eye disorder_________________
Answer ID:6976     [ ]  Congenital anomaly_________________
Answer ID:17611     [ ]  Congenital adrenal hypoplasia_________________
Answer ID:11361     [ ]  Congenital dislocation of hips_________________
Answer ID:11362     [ ]  Cystic fibrosis_________________
Answer ID:6966     [ ]  Diabetes - type 1_________________
Answer ID:6967     [ ]  Diabetes - type 2_________________
Answer ID:17612     [ ]  Congenital hypothyroidism_________________
Answer ID:8309     [ ]  Genetic problems_________________
Answer ID:6968     [ ]  Haemaglobinopathy_________________
Answer ID:16438     [ ]  Haematological disorder_________________
Answer ID:17613     [ ]  Female genital mutilation_________________
Answer ID:6974     [ ]  Hearing disability_________________
Answer ID:6970     [ ]  Hypertensive disorder_________________
Answer ID:7880     [ ]  Mental health_________________
Answer ID:6975     [ ]  Multiple pregnancy (not IVF etc)_________________
Answer ID:6969     [ ]  Pre eclampsia_________________
Answer ID:15728     [ ]  Pregnancy induced hypertension_________________
Answer ID:17614     [ ]  MCADD_________________
Answer ID:13749     [ ]  Thrombosis_________________
Answer ID:6973     [ ]  Tuberculosis_________________
Answer ID:15660     [ ]  Venous Thromboembolism_________________
Answer ID:2275     [ ]  Family history not known
Answer ID:17615     [ ]  PKU_________________
Answer ID:2274     [ ]  Other major condition_________________

Question Text: Have any of your family had mental illness problems that required hospital admission or referral to a psychiatrist?
Question ID: 1226
Question Summary: Family Mental Illness
Table Name: Pregnancy
Field Name: FHMentalHealth
Answer ID:8324     [ ]  No
Answer ID:17616     [ ]  Bipolar disorder_________________
Answer ID:17617     [ ]  Depression_________________
Answer ID:16766     [ ]  Mother had puerperal psychosis
Answer ID:17618     [ ]  Obsessive compulsive disorder_________________
Answer ID:17619     [ ]  Schizophrenia_________________
Answer ID:17620     [ ]  Other_________________