New Life Midwives Intake Form
Email address *
First and Last Name *
Your answer
Partner's First and Last Name ( If applicable)
Your answer
First and Last Name of your Family Doctor (If applicable)
Your answer
Should the need arise, would you be ok with having a student involved your care?
Do you consider yourself to be from a marginalized group(s) based on the following:Teen, Low Income, Immigration Status, Race, Sexuality, Level of Ability, etc.?If so, please list...
Your answer
Date of Birth *
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Home Address (Including postal Code) *
Your answer
Home phone number
Your answer
Cell phone number
Your answer
Can we leave a message on your voicemail?
Email Address
Your answer
First Date of Last Menstrual Period
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Estimated Due Date ( if known)
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Indicate your Transfer Date if this is a surrogate or assisted reproductive pregnancy.
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Is this a surrogate pregnancy?
How many pregnancies have had including this one? *
Your answer
How many vaginal births have you had? *
Your answer
How many C-sections have you had? *
Your answer
Do you have OHIP *
How tall are you?
Your answer
What is your weight in pounds? *
Your answer
Are you a previous Midwifery client? *
Are you a previous New Life Midwife client? *
If you are a previous NLM client, who were your midwives?
Your answer
List any medications, vitamins or supplements you are currently consuming.
Your answer
List any surgeries that you've had in the past.
Your answer
List anything else about you health or obstetrical history.
Your answer
Do you have diabetes *
Do you have high blood pressure *
Do you know where you'd like to give birth?
I acknowledge that New Life Midwives will not have a clinical role during my pregnancy until they have offered and I have attended an in person booking appointment confirming my acceptance into care. *
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