Midwifery INTAKE FORM

Bloom Midwifery Form

*Please Note: email is solely for the purpose of communicating with you regarding your care, informing you of appointments and of up and coming prenatal classes and postpartum events. 

*Please Note: phone calls from your Midwives will come through as "Blocked Number"

Further Information for your Midwifery Team

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

Regarding your Pregnancy, Birth, and Medical History

How many 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.

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?

We would like to acknowledge that the land on which we provide care is the unceded territory of the Coast Salish Peoples, including the territories of the xʷməθkwəy̓əm (Musqueam), Skwxwú7mesh (Squamish), Stó:lō and Səl̓ílwətaʔ/Selilwitulh (Tsleil-Waututh) Nations.

 

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