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 email to confirm that we can take you into care or that your have been added to our wait list.

Please note that all of the information collected is private and confidential. See our privacy policy at the bottom of this page.

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 the father:
Your answer
Is the father of the baby involved?
Did you take a home pregnancy test?
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
If yes, when was your Cesarean Section?
MM
/
DD
/
YYYY
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 a family doctor?
If yes, please provide his/her telephone number and fax number
Your answer
Height
Your answer
Weight
Your answer
Are you a repeat client?
Have you ever had a midwife before?
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