Your Name (As It Appears On Your BC Health Care Card)
Care Card Number   Maiden Name
Birth Date   Age   Employer
Single? yes no    if not, partners name   Partners Age
Partners Employer
Marital status common law married -   Length of relationship
Address   Postal code   Neighbourhood
Home phone   Cel Phone   Work phone
Email address
General practitioner   Maternity/OB
Any Allergies? Describe Reaction:
What was the date of the first day of your last period?
Are your periods regular? yes no
How many days are usually between cycles?
What contraception were you using prior to becoming pregnant?
Are you taking folic acid? yes no   If so, when did you start?
Date baby is due (if known)
Most recent PAP test date
How many times have you been pregnant?
How many children do you have?
If you have other children:
Delivery dates
Were they early or late by due date?
Current pregnancy symptoms:


Brief health history, including any medical concerns:


Height   Pre-pregnancy weight   Blood group

Medications

Brief history of previous pregnancies/births (normal, any complications?):


Reasons for midwifery care:


How did you hear about us?