Eastbourne Clinic Mother and Baby Enquiry Form

Mother & Baby Enquiry Form

This information is requested so that we can offer appropriate advice / support for those who request it. All information is treated in the strictest confidence in accordance with the Data Protection Act. Those who prefer not to answer some of the questions below are under no obligation to do so.

1. Please provide the following contact information:
(Fields marked with a * are required.)

Title:	*
Full Name:	*
Address:	*

County:	*
Post Code:	*
Telephone Number:	*
E-Mail:

2. How old is the baby? (in months)

3. The baby is my ... (enter first, second, etc.):

4. Select the baby's sex:

5. I have been unwell for (months):

6. Have you seen a doctor?

	Yes
	No

7. If Yes to question 6 above - what did the doctor prescribe?

8. My doctor has given me a diagnosis of:

9. Were you depressed while pregnant?

	Yes
	No

10. Did you suffer from depression before pregnancy?

	Yes
	No

11. Have you suffered from previous mental illness?

	Yes
	No

12. The main features / symptoms of my illness now are:

13. Please tell us any information that you feel is relevant or helpful to us:

If you are okay with the information entered please click on the SEND FORM button below:

©2006, The Eastbourne Clinic
The Eastbourne Clinic, Grange Road, Eastbourne, East Sussex BN21 4HE
Telephone: (01323) 430831

All information is subject to change without notice, please feel free to contact us for more information.