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Intake Form
* = required fields
About You
Name: *
Do you have a partner?:
Yes
No
Partner's name:
Language spoken at home:
Your date of birth: *
Month
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Feb
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Year
Address: *
City: *
Postal code: *
Home Phone Number: *
May we leave a message at this number?
Yes
No
Work Phone Number:
May we leave a message at this number?
Yes
No
Cell Phone Number:
May we leave a message at this number?
Yes
No
Email Address:
About Your Health
Due date:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
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31
Year
Not Sure
First day of your last menstrual period:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
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31
Year
Not Sure
How many pregnancies have you had including this one?:
How many births have you had?:
Vaginal:
1
2
3
4
5
6
7
8
9
10
11
12
C-section:
1
2
3
4
5
6
7
8
9
10
11
12
and where did you birth?:
Do you have any medical problems?:
Yes
No
Please describe:
Did you have any problems with a previous pregnancy or birth?:
Yes
No
Please describe:
Have your received any prenatal care during this pregnancy?
Not yet
Family doctor
Obstetrician
Walk-in
Midwife
If yes, what:
Bloodwork
Pap smear
Ultrasound
Pregnancy test only
Do you have a family doctor or nurse practitioner?:
Yes
No
Name:
Where do you plan to deliver your baby?
Home
Hospital
Undecided
Is there anything else about your family or your health that you would like us to know at this time?
Other Details
Have you been previously cared for by an Ontario midwife?
How did you hear about us?
Are you an American Citizen or a Non Resident of Canada?
(this will not affect your ability to access midwifery care)
Yes
No
Consent for release of information to Ontario Ministry of Health and Long Term Care. For billing purposes we are required to release some statistical information about you and your pregnancy to the Ministry of Health. Your name is not used, however some identifiers like yours postal code, your date of birth, and information about your care with midwives will be shared with the Ministry. Please check this box if you agree we may forward this information for billing purposes:
Agree
Disagree
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