Midwifery Client Intake & Medical History Form

Client Intake & Medical History Form

Please make sure to complete all required fields.
Client Full Name*

First NameMiddle NameLast NameSuffix
Client Preferred Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number

Area CodePhone Number
Mobile Phone Number

Area CodePhone Number
E-mail
How were you referred to me?
Partner Information
Partner's Full Name*

First NameMiddle NameLast NameSuffix
Address (if different than mother)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Partner's Phone Number

Area CodePhone Number
Partner's Birth Date*

MonthDayYear
State of Birth
or Foreign Country of Birth
Partner's Education*
Occupation*
Industry

Emergency Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship
Insurance Status
Self-PayMedicaid/FAMISAnthem/Blue Cross Blue ShieldAetnaCignaUnited HealthcareFlexible Spending AccountHealthcare Savings AccountOther
Insurance ID Number
Insurance Group Number
Who is the primary insured person:
Relationship to the primary insured person:
What is that person's date of birth (if not, self)?
Employer Associated with Insurance Provider:
Is there another insurance plan?
If there is another insurance plan, please list all of the insurance information listed above for the secondary plan:

Client Health History
1. Allegy or Sensativities*
Propensity is when several members of family have allergy or intolerance
Additional Information about allergies or sensitivities

Family History
Mother's Obstetrical History - If known, please list how many times your mother was pregnant, any complications, length of labors, baby weights, and any other information you feel is relevant:
We are blood related.Previous child with birth defect or mental retardation.Family members with genetically inherited conditions or illnesses.Jewish, African, Asian, or Mediterranean ancestry.NoneOther
1. Family Member
Medical Condition
2. Family Member
Medical Condition
3. Family Member
Medical Condition
4. Family Member
Medical Condition
5. Family Member
Medical Condition
6. Family Member
Medical Condition
7. Family Member
Medical Condition
8. Family Member
Medical Condition
Additional Information

Birth Education, Support, Barriers, and Desires
Have you researched the safety and responsibility of homebirth?
Do you feel that you are a healthy, low-risk woman? Why/Why not?
Will your family and friends support your decision to homebirth?
Do you expect any obstacles to you birthing at home without complications?
Do you have any pregnancy, birth, or parenting related fears?
Do you feel like you will have adequate postpartum support?
What financial option and payment schedule works best for your family? Please include any financial concerns you have as well.
Tell me about your desires for this pregnancy and birth:
What, if any, childbirth education classes, videos, and books will you be using during this pregnancy?
Should be Empty:

Client Intake & Medical History Form