Midwifery INTAKE FORM
Do you have a preferred team at Bloom?
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?