INTAKE FORM

Only fill in this form AFTER you have contacted WestCoast Midwives at (250)384-5940

This form consists of a number of questions we use to determine if care through this clinic is the best choice of care for you.

Verification Code	Refresh - Caution! This will reset the form.
Your Name	(As It Appears On Your BC Health Care Card)
Care Card Number
Maiden Name
Birth Date	DD/MM/YYYY
Age
Employer
Single	Yes No
If not single, Partner's Name	Partner's Age
Partner's Employer
Marital Status	Married Common Law
Length of Relationship
Address
City	Postal Code
Home Phone	Cell Phone   Work Phone
Email Address
General Practitioner
Medications
Height	Pre-pregnancy weight
Date of the first day of your last period
Do you have regular periods?	Yes No
Usual number of days between cycles
Type of Contraception used prior to pregnancy
Are you taking Folic Acid?	Yes No
If taking Folic Acid, what date did you start?
Most recent Pap Test date
Number of Pregnancies
Number of Children
If you have had other children, please enter the delivery dates
Were they early or late by due date?
Brief history of previous pregnancies/births (normal, any complications?)
Brief health history including any medical concerns