MIDWIFERY CARE INTAKE FORM
YOU  
Your name required
If you have a partner, what is his/her name?
Email address required

Address



City/Region:
Postal:
Home phone
Cell phone
Work phone
Date of birth

Do you have MSP?


How would you describe your health prior to becoming pregnant?
How is your health now that you are pregnant?
   
YOUR PREGNANCY
Have you had any prenatal visits, labs or tests in this pregnancy yet?







If yes, what:
only
When are you due?
 
When was your last period?
Approximately how many days long are your menstrual cycles?
 
This is baby #
If this is not your first baby:
  What type of birth(s) have you had?
  Where did you birth?


City/hospital:

  Who was your care provider(s)?




MIDWIFERY CARE
Have any of your friends or family had midwifery care? Who:
Do you know anyone who has had care at Pomegranate? Who:
How did you hear about Pomegranate?


We offer a choice of birthplaces. Do you have an initial preference?
  If you are thinking hospital, which one?

(must have a Vancouver address)

Are there any particular midwives at Pomegranate that you would like to work with?

Wondering where some of our recent midwives have gone? Please note the following changes upcoming at Pomegranate:

  • SUSIE SCHULZ is starting the first team to offer homebirth as an option at the South Community Birth Program, in 2012. If you are due then, please contact www.scbp.ca.
  • BETH EBERS and LESLIE GUNNING are starting the first midwifery practice in Squamish, and can be reached at 604-815-0026.
In addition to English, midwives at Pomegranate are able to offer some care in Spanish, French, Dutch, Czech, Hebrew or ASL. Does this interest you?
Is there anything else about yourself or your health you would like us to know? Feel free to let us know what interests you about midwifery care.