Midwifery INTAKE FORM

Bloom Midwifery Form

Is there a partner or support person involved in your pregnancy? (if yes, name/relationship/phone number)

Is there anything else you want us to know? (eg Team Preferences)

Have you received any prenatal care in this pregnancy?

(If yes, where/with whom/how many visits)

Is this your first pregnancy? If not, how many pregnancies and/or births have you had? Please provide details on previous births, if applicable.

Did you experience any health complications in your previous pregnancies or births?

If you have a Family Doctor, please list their name, clinic, and phone number.

Thank you! We will be in touch in 1-3 business days.

Do you have a preferred place of birth?

When was the first day of your last normal menstrual period (day/month/year)?

What is your Estimated Due Date (day/month/year)

Have you had any tests yet in this pregnancy e.g. ultrasounds or blood work.

(If yes, which ones?)

Do you have any serious medical or health issues we should know about?