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Intake Form

*Full Name *Birthdate
*Health Card Number   Partner Name
*Address
*City *Postal Code
*Contact Phone 1 Contact Phone 2
*Height *Weight
*First day of last menstrual cycle?

*How long is your menstrual cycle?

*Do you have regular menstrual cycles?

*How many pregnancies have you had?

*How many vaginal deliveries?

*How many cesarean sections?

*Do you have any pre-existing medical conditions or any reason to believe you may be high risk? If yes, please explain

*Do you take any medications?

*Are you interested in prenatal screening? (IPS/Panorama/Amniocentesis/CVS)

*Have you had a midwife before? If so, who?

*Name of family physician/nurse practitioner?

*How did you hear about us?

Comments

*The Ministry of Health is collecting data on the demand for Midwifery Services. If we are unable to provide care to you during your pregnancy, may we have your consent to share your name, date of birth, postal code and due date with the Ministry of Health? This will allow the Ministry of Health to evaluate how many women are unable to access Midwifery Services

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