Pomegranate Community Midwives | HOME

MIDWIFERY CARE INTAKE FORM
YOU
Your name required
If you have a partner, what is his/her name?
Email address required
Address If your city/region is not listed, please call our office to see if we are taking clients in your neighborhood.		Street: City/Region: Postal:
Home phone
Cell phone
Work phone
Date of birth
Do you have MSP?		Yes Number (without spaces): Name as written on card: No Waiting for
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 care in this pregnancy yet?		Not yet If yes, from who: Family doctor Obstetrician Walk-in Midwife	If yes, what: Pregnancy test Bloodwork Pap smear Ultrasound
When are you due?
If you aren't sure:
	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?	Cesarean birth: how many? Vaginal birth
	Where did you birth?	Home Hospital City/hospital:
	Who was your care provider(s)?	Midwife GP OB
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?		Referral - from: Past client - who: Internet Advertising Live in neighborhood Other
We have privileges at 3 hospitals. We also are more than happy to help you have a home birth. Do you have an initial preference?		HOME BC Women's (must live in Vancouver) St. Paul's Burnaby Hospital STILL DECIDING
Are there any particular midwives at Pomegranate that you would like to work with?
In addition to English, midwives at Pomegranate are able to offer some care in Spanish, 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.