Pre-Eclampsia screening

First Name

Last Name

Email Address

Phone

Date of Birth

Are you having a single or multiple pregnancy? *

SingleMultiple (i.e., twins, triplets)

Are you currently taking any anti-coagulants (e.g. aspirin)? *

YesNo

Please state your ethnicity: *

Smoking Currently *

NoYesSmoker

Do you suffer from Diabetes? *

Yes - type 1Yes - type 2No

Do you suffer from chronic hypertension? *

Yes No

Do you suffer from System Lupus Erythematosus? *

YesNo

Do you suffer from Antiphospholipid Syndrome? *

YesNoDon't know

Did your Mother ever experience Pre-Eclampsia? *

YesNoUnknown

Conception details *

SpontaneousIVFVia Ovulation Inducing Drugs

Ovulation details *

Not inducedVia Ovulation Inducing drugs

IVF details *

Patient's own eggDonor provided egg

What was the date of collection of your egg? *

What age were you when the egg was extracted? *

What is the DOB of the donor? If unknown, what was their age at the time of donation? *

Have you had a previous pregnancy that has gone past 23 weeks? *

YesNo

Have you previously had any of the following trisomies? *

Tr21Tr18Tr13None of the above

Have you experienced Pre-Eclampsia in any previous pregnancies? *

YesNoNot applicable

Have you experienced Fetal Growth Restriction in a previous pregnancy? *

YesNoNot applicable

How many previous pregnancies have had between 16-30 weeks? *

How many previous pregnancies have you had between 31-36 weeks? *

How many previous pregnancies have you had of more than 37 weeks? *

For your most recent pregnancy > 23 weeks, what was the delivery date? *

And what was the gestational age at the time of delivery? *