Community Midwives of Brantford Intake Form
If you would like to request care from our midwives, please fill out this form in its entirety. Fields indicated by a red star are required. Your request will be sent directly to us and our support staff will contact you if we are able to provide you with care.
If you would prefer to provide your details by phone or are experiencing difficulty with this form please feel free to contact us at: 519-751-6444.
* Required
What is your name?
Your answer
Maiden Name?
Your answer
Do you have a health card (OHIP)?
*
Yes
No
Your birthday.
*
MM
/
DD
/
YYYY
Your phone number.
*
Your answer
Is it okay to leave messages at this number?
Yes
No
Clear selection
Your email.
Your answer
Your street address.
*
Your answer
Your town / city.
*
Your answer
Your postal code.
*
Your answer
What is your partner's name?
Your answer
Have you ever had a midwife before?
Yes
No
Clear selection
If you have, do you remember who?
Your answer
What is your estimated due date?
MM
/
DD
/
YYYY
When was the first day of your most recent menstrual period (LMP)? Please note that we are unable to process your form without an LMP or due date.
MM
/
DD
/
YYYY
How long is your cycle?
*
Your answer
How many times have you been pregnant (including this pregnancy?)
*
Your answer
How many vaginal births have you had?
*
Your answer
How many C-section births have you had?
*
Your answer
If you've had a cesarean, do you remember why? Please explain.
Your answer
If you've had a C-section previously, what is your hope/plan for this birth?
A vaginal birth
Another C-section
Clear selection
If this is not your first baby, when was your last baby born?
MM
/
DD
/
YYYY
Have you given birth before 37 weeks?
*
Yes
No
Not sure
Did you have any complications with a previous pregnancy or birth?
Diabetes
High Blood Pressure
Cholestasis
Multiples
More than three miscarriages
Pre-Eclampsia
Pre-Term Delivery
Post-Partum Hemorrage requiring transfusion
Other:
If yes, please provide more information about the complication.
Your answer
Do you have a preexisting health condition?
Diabetic
Epilepsy
Cardiac / Liver Disease
Pelvic Break / Trauma
HIV
Other:
If yes, please provide more information about their duration, severity and what treatment (if any) you are receiving.
Your answer
Are you currently taking any medications (including vitamins)?
Yes
No
Clear selection
If yes, what medications?
Your answer
Do you want a home or hospital birth?
Home
Hospital
Undecided
Clear selection
Who is your family doctor? Please include their address and phone number.
Your answer
How did you hear about Community Midwives of Brantford?
Choose
Internet Search
Advertisement
Friend
Other
Why are you seeking midwifery care?
Your answer
Anything else you'd like to tell us?
Your answer
The Ministry of Health and Long Term Care asks us for some information about people seeking midwifery care to track the demand for midwives in the province. May we give your information to the Ministry of Health for this purpose? Your information is kept confidential
Yes
No
Clear selection
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
