Midwifery INTAKE FORM
What is your preferred language? (Midwives speak English, French, Arabic, and German)
Regarding your Current Pregnancy
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 received any prenatal care in this pregnancy?
(If yes, where/with whom/how many visits)
Have you had any tests yet in this pregnancy e.g. ultrasounds or blood work.
(If yes, which ones?)
Where would you prefer to give birth? (Home/Hospital/Undecided)
Do you have any serious medical or health issues we should know about?
Is this your first pregnancy? If not, how many pregnancies have you had?