Midwifery Client Intake & Medical History Form

Client Intake & Medical History Form
This form takes about 30 minutes to complete. Please make sure to complete all required fields. Many questions are required to complete birth certificate.
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
Work 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 Social Security Number
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

Client Health History
1. Allegy or Sensativities
Propensity is when several members of family have allergy or intolerance
First Known Date
MonthDayYear
Product
Reaction
2. Allegy or Sensativities
Propensity is when several members of family have allergy or intolerance
First Known Date
MonthDayYear
Product
Reaction
3. Allegy or Sensativities
Propensity is when several members of family have allergy or intolerance
First Known Date
MonthDayYear
Product
Reaction

Family History
Mother's Obstetrical History - Please list how many times your mother was pregnant, any complications, length of labors, baby weights, and any other information you feel is relevant:
Genetic Factors - Please check if any of the above apply to you or the father of the baby:
Other
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 childbirth education classes, videos, and books will you be using during this pregnancy?
Should be Empty:

Client Intake & Medical History Form