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(1292010120529 PM) B - Maternity Enrolment Form - English
(1292010120529 PM) B - Maternity Enrolment Form - English
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Option
I authorise my medical practitioner to furnish and/or disclose to GEMS any fact relating to this application as well as any additional information that may be required from time to time.
Date D D M M Y Y Y Y
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Medical information:
Weight Smoking kg Height cm
n Yes n No If YES, how many per day? n If NO n Never n Stopped less than 3 months ago n Stopped more than 3 months ago Exercise n Never n Less than 1 hour/week n 1-3 hours/week n More than 3 hours/week Allergies n Penicillin n Aspirin n Sulphonamides
Other
PLEASE COMPLETE THE SECTION BELOW (or refer to attending doctor or caregiver)
n Yes n No
n Yes n No If YES, how much? More than two glasses per day? n Yes n No Expected delivery date: Date nnnnnnnn First day of last menstruation period nnnnnnnn D D M M Y Y Y Y D D M M Y Y Y Y
nn n Yes n No
nn
Do you have triplets?
n Yes n No
Have you previously experienced a miscarriage, stillbirth, death of a baby in the first 4 weeks or an ectopic pregnancy?
n Yes n No
Were any of your babies born with health problems, eg. premature, spinal cord defects, congenital defects or late still birth?
n Yes n No
Have you had amniocentesis tests (extraction of fluid from your uterus during pregnancy) carried out for you?
n Yes n No
Were any of your babies born prematurely? How were your children delivered?
n Normal vaginal birth n Caesarean birth Weight of babies? Under 2500g n Yes n No Over 4300g n Yes n No
Did you experience any of the following during a vaginal birth:
n Yes n No
n Yes n No
What was the reason for the caesarean birth? (if applicable)
If any other problems were experienced, please provide us with more details
Indicate if any of the following complications were experienced after the birth of your child.
n Placenta retention n Postnatal depression n Severe bleeding n Breast problems n Wound infection
Condition of baby/ies after delivery:
n Breathing problems n Neonatal jaundice n Bleeding under scalp n Paralysis Did you breastfeed your baby/ies? n Yes n No
(Yellowing of newborns skin)
n Other
If YES, how many weeks/months/years? THANK YOU FOR COMPLETING THE FORM. Please fax the completed form to 0861 00 4367. Should you have any queries, please contact 0860 00 4367 or send an email to enquiries@gems.gov.za
IMPORTANT: You must discuss all health and treatment issues with your doctor first.
Tel 0860 00 4367 Fax 0861 00 4367 enquiries@gems.gov.za www.gems.gov.za