Intake Form - Blue Heron Midwives

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Intake Form

Congratulations on your pregnancy!

Midwives are primary care providers who specialize in low risk pregnancy and birth.
In Ontario, you can choose to have a midwife or a doctor (OB/FP) look after you when you’re pregnant, but not both. This means that unless there is a complication, your midwife will provide all the care you need in office and at your hospital birth.
For more information please visit the AOM website.

If you would like to learn more about midwifery care please spend some time on our website, or speak with Fran or Pavneet our administrators. Due to our busy clinic schedule it is not possible to book an interview appointment with our midwives.

Intake Form

First Name

Last Name

Email

Address

Address Line 1

Address Line 2

City

Postal code

Phone number

Date of birth:

What type of health insurance do you have?

Ontario Health Card(OHIP)

CHIP/CIHIP

UHIP

IFH

Private Insurance

None

Please provide details of your status in Canada

Will your health insurance cover the full cost of the pregnancy?

Yes

No

Language

Do you require an interpreter?

Yes

No

Do you know the start date to your last period?

Yes

No

First day of last period

Please provide details known about last period

Are your periods regular?

Yes

No

Please provide details about period regularity

Length of cycle in days?

Length of cycle in days:

Estimated Due Date

Medical History

Please select preffered units for measurements

Metric

Imperial

Pre-pregnancy weight in lbs

Pre-pregnancy weight in kgs

Height in inches

Height in cm

BMI

Do you have a family doctor?

Yes

No

Doctor name

Doctor phone number

Past or present medical conditions

Please provide details about Major health conditions or surgeries

Please provide details about diabetes

Please provide details about lung problems

Please provide details about high blood pressure

Please provide details about heart issues

Please provide details about epilepsy

Please provide details about kidney disease

Please provide details about blood clotting issues

Please provide details about mental health issues

Please provide details about other medical conditions

Please list all medications you are currently taking and for what purpose:

How many times have you been pregnant including this pregnancy?

How many vaginal deliveries?

How many C-Sections?

Please provide details of your previous pregnancies and deliveries including any complications:

Have you had a midwife before?

Yes

No

Have you delivered at home before?

Yes

No

Are you a repeat Blue Heron Midwives client?

Yes

No

Is this a referral from an agency?

Yes

No

Please provide details about your referral

Where would you like to deliver?

Home

Grand River Hospital

Undecided

Have you had prenatal care yet this pregnancy?

Have you had any of the following done in this pregnancy?

Blood work

Yes

No

Ultrasound

Yes

No

The Ministry of Health and Long-Term Care collects data who seeks midwifery services. Do we have consent from you to forward your Name, Date of Birth, and Postal Code to the MOH for this data purposes?

Yes

No

If you come into our care, would you like your name added to our contact list?

Yes

No

Midwives are primary care providers who specialize in low-risk pregnancy and birth. In Ontario, you can choose to have a midwife or a doctor (OB/FP) look after you when you’re pregnant, but not both. Please acknowledge that you are choosing midwifery care:

Yes

No

Are you interested in learning more about free Breastfeeding Buddies resources?

Yes

No

The midwives discuss all possible intakes at our regular practice meeting on Tuesday afternoon. Our administrator will be in touch on Tuesday after the meeting to let you know if you have been accepted into care or added to our wait list.

If you have any questions or are having difficulty filling out the form please call our office during our regular business hour: Monday to Thursday 9am to 12pm & 1pm to 5pm.

Email: info@blueheronmidwives.com
Phone: (519) 954-0300
Fax: (519) 954-8861

Location:
30 Dupont St E #105,
Waterloo, ON
N2J 2G9

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Blue Heron Midwives acknowledges that our office location and much of our work takes place on the traditional territory of the Neutral, Anishnaabeg, and Haudenosauonee peoples. Our office is located on the Haldimand Tract, the land granted to the Six Nations that include six miles on each side of the Grand River.

About our Practice
- Our Team
- When Coming to our Clinic
Midwifery Care
Our Programs
- Connecting Pregnancy
- New Baby Time
Calendar
Contact