The Hamilton Midwives Client Intake Form

First name

Last name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone number

Area CodePhone Number

Email

Age

Date of Birth

DayMonthYear

Date of Birth (formatted)

Are you a resident of Ontario?

How many times have you ever been pregnant (including this time)?

How many living children do you have?

Have you had midwifery care in Ontario before?

Who were your midwives?

Did you have any problems in your previous pregnancy(s)

Please describe

How many were vaginal birth(s)?

How many were caesarean sections?

If you would like to request particular midwives, please list them here.

What was the first day of your last menstrual cycle?

DayMonthYear

First day of last menstrual cycle (formatted)

Have you had a dating ultrasound?

If known, what is your due date?

DayMonthYear

Due date (if known) (formatted)

Where do you plan to have your baby?

Do or did you have any medical problems, presently or in the past?

Please describe

Are you on medication at this time?

Please describe

Height

Weight

Family Doctor's Name

Family Doctor's City

Enter the message as it's shown

Accepted for Care

If No, Why

Date of Acceptance

Midwifery Care Team

Midwife 1

Midwifery Care Team

Midwife 2

Midwifery Care Team

Midwife 3

Midwifery Care Team

Midwife 4

Date of First Visit

Client Code

NOTES