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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: *
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Address: *
City: *
Postal code: *
Phone Number: *
May we leave a message at this number?
Yes
No
Email Address:
About Your Health
Due date:
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Not Sure
First day of your last menstrual period:
Month
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Not Sure
How many pregnancies have you had including this one?:
How many births have you had?:
Vaginal:
1
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12
C-section:
1
2
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5
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11
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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?
Midwives of Headwater Hills offers home birth or delivery at Headwaters Health Care Centre Hospital in Orangeville.
Home
Headwaters Health Care Centre
Undecided
What are your hopes and goals for care with a midwife?
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?
Yes
No
Name of Clinic and Midwife:
How did you hear about us?
Do you maintain a current home address in Ontario?
Yes
No
Do you have a valid OHIP card?
(this will not affect your ability to access midwifery care)
Yes
No
Are you an American Citizen or a Non Resident of Canada?
(this will not affect your ability to access midwifery care)
Yes
No
By clicking submit, you acknowledge that Midwives of Headwater Hills is required to release statistical information about your pregnancy and birth to the Ontario Ministry of Health and Long Term Care for billing purposes. If you have questions about this, please call our office before submitting your intake form.
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