Request for Care Personal InformationName Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Address Street Address Address Line 2 City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone NumberCell Phone NumberWork Phone NumberHealth Card NumberEmail Birthdate MM slash DD slash YYYY Health BackgroundHave you had a midwife before?YesNoIf yes, Midwife's nameWhat was the DATE of the first day of your last menstrual period MM slash DD slash YYYY How many days in your menstrual cycle (i.e 28 days)Are your cycles regularYesNoDue Date if known MM slash DD slash YYYY Determined by (Home test? Ultrasound?)How many times have you been pregnant including this pregnancy?How many vaginal deliveries have you had?Please enter a number from 0 to 25.How many Caesarean sections have you had?Please enter a number from 0 to 25.Have you had any of the following?Ultrasound Yes No Prenatal Bloodwork Yes No Is there any reason to believe that you are high risk? Yes No If yes please explainWhere are you planning to give birth?HospitalOut of hospitalHeight? ft' in": cm:Weight? lbs: kg:Do you have any pre-existing medical conditions? Yes No If yes, what are they?Any additional information?How did you hear about Sudbury Community Midwives?The Ministry of Health is collecting data on the demand for Midwifery Services. If we are unable to provide care to you during your pregnancy, may we have your consent to share your name, D.O.B., postal code, and due date with the Ministry of Health? This will allow the Ministry of Health to evaluate how many women are unable to access Midwifery Services.Do we have your consent? Yes No Δ