Intake Form
Thank you for your interest in receiving midwifery care with us.

Please complete the form below as accurately and completely as you can.

We will contact you by phone or email if we are able to take you into care. We review forms and due dates every few weeks so you may not get a call immediately but that does not mean you won’t!

Please note that all of the information collected is private and confidential.

Full Name: *
First and last name
Your answer
Street Address: *
Your answer
City: *
Your answer
Postal Code: *
Your answer
Email: *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Health card number:
Your answer
Primary telephone number: *
Your answer
Language spoken:
Your answer
Name of your partner:
Your answer
Did you take a home pregnancy test?
Where do you plan to deliver
Have you seen a physician or other health care provider for prenatal care?
Have you had an ultrasound during this pregnancy?
If yes, do you have a due date based on an ultrasound?
Please tell us when you are due.
MM
/
DD
/
YYYY
First day of your last period. *
MM
/
DD
/
YYYY
How long are your menstrual cycles? *
For example, 28 days
Your answer
Are your menstrual cycles regular? *
Every month
How many pregnancies have you had? *
Including this pregnancy, any abortions, miscarriages or terminations.
Your answer
How many of your babies were born at term? *
After 37 weeks gestational age
Your answer
How many of your babies were born premature? *
Before 37 weeks gestational age but after 20 weeks.
Your answer
Have you ever had any abortions, miscarriages or terminations? *
Your answer
How many children do you have? *
Your answer
Have you ever had a Cesarean Section? *
Required
Have you ever had any complications during any of your pregnancies, your baby or postpartum?
Such as gestational diabetes, high blood pressure or postpartum hemorrhage
If yes, what were the complications?
Your answer
Do you have any medical concerns or health issues? If yes, please list.
Your answer
Do you take any medications, vitamins or natural supplements? If yes, please list.
Your answer
Do you have any allergies- medication, environmental or food? What is your reaction?
Your answer
Do you have a family doctor?
If yes, please provide his/her name and telephone number and fax number
Your answer
Height *
Your answer
Weight *
Your answer
Any additional information we should know?
Your answer
Are you a repeat client? *
Have you ever had a midwife before?
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