Born Midwives

Last Name*

on health card

First Name*

Last Name

if different from your health card

If applicable, what is your partners name?

Email

Your Birth Date

Address*

Street Address City Postal Code

What was the first day of your last menstrual period?

Home Phone*

Cell Phone

Where can we leave you a message?

What is your due date (if you know)?

Where do you plan on having your baby?

How many times have you been pregnant, including this pregnancy?*

How many times have you given birth?*

How many were vaginal births?*

How many were cesarean births?*

Have you had a midwife before?

Do you have any health problems? (including insulin dependent diabetes, heart disease, kidney disease, BMI >/=50, HIV)*

Have you had a baby earlier than 35 weeks (more than five weeks before the due date)?*

Did you have any problems in another pregnancy, birth, or after the baby was born?

Are you a smoker or do you reside with a smoker

How did you hear about us?*

Is there anything else you'd like us to know?

Have you seen a care provider during this pregnancy?*