Register - Kitchener-Waterloo Midwifery Associates

CONTACT INFORMATION

Name:

First Last

(First and last names as shown on Health Card only)

Address:

Street Address City Postal Code

Apartment Number:

Buzzer Number:

Primary Phone Number:

(if we need to re-schedule your appointment)

Secondary Phone Number:

Email Address:

MEDICAL INFORMATION

Height (in cm only):

Weight in kg only (before pregnancy):

Full Name & Phone number of Family Physician:

Have you ever had a midwife before?

Yes
No

Have you signed up at another midwifery?

Yes
No

How many times have you been pregnant (including this pregnancy)?

How many children do you have?

How many home births have you had?

How many Caesarian sections have you had?

When was the first day of your last menstrual period?

eg. Feb. 6, 2016

How often do you get your periods?

Are your cycles regular?

Yes
No

Where are you planning to give birth?

How did you hear about KW Midwifery Associates?

Do you have any major medical conditions including any that occurred during any previous pregnancy?

Are you currently on any prescription medications?

Yes
No

Please list your current medications:

Additional information:

Do you have any specific midwife requests?

NOTE: The Ministry of Health is collecting data on the demand for midwives. May we have your consent to share your health card number when we receive it? This information will help get more midwives in the area.

Yes
No

Number

Yes, send me email updates about KWMA events and information.