Client Intake Form

First Name:*

Last Name:*

Home Address:*

City:

Postal Code:*

Home phone number:*

Cell phone number:
Work phone number:
Email Address:*

Name of partner/husband:

Name of doctor:

Date of birth: (month/day/year)*

January February March April May June July August September October November December

Height:

Weight [before getting pregnant]:

Date of first day of last period:

Are your cycles regular?

How often are your periods? [eg 28 days]

Which pregnancy is this for you? [eg 1st, 2nd...]

If you have been pregnant before, please answer the following:

Please tell us about your pregnancies, including any miscarriages you have had and tell us how many pregnancies you have had:

Did you have any pre-term deliveries?

Did you ever deliver with the assistance of forceps or vacuum?

Did you ever deliver by cesarean section?

Did you have any medical complications in any pregnancy?

Did you have any complications in any delivery?

Did you ever deliver at home?

Have you had an ultrasound this pregnancy?

Have you had bloodwork done by your doctor this pregnancy?

List of prescription medications you take:

Medical conditions:

Allergies:

Have you had a midwife before?

What led you to contact Thames Valley Midwives?

 

We will contact you at our earliest convenience to let you know if we have a place for you in our care.