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Midwifery Client Intake And Medical History Form
This form takes about 10 minutes to complete. Please make sure to complete all required fields. These questions are pertinent to make sure you are safe for full-scope midwifery care.
35
Questions
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1
Client Full Name
*
This field is required.
First Name
Middle Name
Last Name
Suffix
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2
Date of Birth
*
This field is required.
-
Date
Year
Month
Day
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3
Mobile Phone Number
*
This field is required.
Area Code
Phone Number
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4
E-mail
*
This field is required.
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5
Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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6
How were you referred to me?
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7
Marital Status
*
This field is required.
Please Select
Married
Divorced
Seperated
Never Married
Widowed
Please Select
Please Select
Married
Divorced
Seperated
Never Married
Widowed
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8
Pre-pregnancy weight
*
This field is required.
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9
Height
*
This field is required.
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10
Prescription Medications and Doses
*
This field is required.
Example: Tylenol 500mg three times a day
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11
Supplements
Prenatal Vitamins
Iron
Calcium
Vitamin D
Fish Oil
Magnesium
Other
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12
Other
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13
Check if you have EVER been diagnosed or suspected to have any of the following:
*
This field is required.
Diabetes
Hypertension
Seizures/Epilepsy
Heart Disease
Cancer
Thyroid Issues
Blood Disorder
Anemia
Asthma
Allergies
Hepatitis
Kidney Problems
HIV Exposure
Liver Problems
Tuberculosis (TB)
Urinary/Bladder Problems
Pelvis/Back Problems
Stomach/Digestive Issues
Skin Disorders
Bladder Infection
Kidney Infection
Severe Headaches
Ear/Hearing Problems
Eye/Vision Problems
Vascular Issues (varicose veins, blood clots, etc.)
Hemorrhoids
None
Other
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14
Describe any checked boxes here
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15
Procedures/Surgeries
Gallbladder Removal
Appendix Removal
Tonsil Removal
Orthopedic Surgery
Spine/Pelvis Surgery
Bladder Surgery
None
Other
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16
Describe any checked boxes here
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17
Please check if you have ever been diagnosed or suspected of having any of the following:
*
This field is required.
Depression - requiring therapy
Bi-Polar Disorder
Anxiety
Panic Attacks
Postpartum Depression
Delusions
Paranoia
Psychosis
Anorexia
Bulimia
PTSD
Addictiion
None
Other
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18
Please provide additional information about any items checked above. You may include dates, circumstances, and treatments used.
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19
Check All That Apply
*
This field is required.
Breast Lumps
Cervical Disorder
DES Exposure
Female Circumcision
Fibroids
GBS
Infertility
Other GYN Disorders
Ovarian Cysts
PID
Prior Contraception Use
Uterine Surgery
Yeast Infection
Bacterial Vaginosis
Group B Strep
Abnormal Pap Smear
Cervical/Uterine Abnormalities
Previous Gynecological Surgeries/Procedures
PCOS
Endometriosis
Endometritis
Gynecological Cancer
Cervical Biopsy
Cryosurgery
LEEP Procedure
None of the Above
Other
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20
Describe any previously checked boxes here
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21
STD History
*
This field is required.
Chlamydia
Gonorrhea
Herpes
HIV
Infection in Tubes or Uterus (PID)
Syphillis
Never Tested
Other STD
Negative
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22
Describe any checked boxes here
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23
First Day of Last Period
*
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-
Month
Day
Year
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24
What is your estimated due date?
-
Month
Day
Year
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25
Have you seen a provider for this pregnancy?
*
This field is required.
Yes
No
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26
If so, who?
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27
Number of Pregnancies - Including current pregnancy.
*
This field is required.
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28
Pregnancies Delivered after 37 Weeks
*
This field is required.
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29
Pregnancies Delivered Before 37 Weeks
*
This field is required.
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30
Miscarrages
*
This field is required.
Pregnancy loss before 20 weeks
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31
Abortions
*
This field is required.
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32
Number of Children Now Living
*
This field is required.
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33
Have you ever had:
*
This field is required.
Ectopic/Tubal Pregnancy
Twins or higher multiples
Preeclampsia
Gestational Diabetes
Shoulder Dystocia (shoulders got stuck after head came out)
3rd or 4th Degree Tear
C-Section
Retained Placenta
Excessive Postpartum Bleeding
Low Birth Weight Baby - less than 6lbs
Macrosomic Baby - 9lbs or greater
Stillbirth
None of the above
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34
Please elaborate on any previously checked items:
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35
Appointment
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