* required fields Client Information First name Last name How many weeks pregnant? Baby’s due date Address Address City/Town Postal Code Home phone Language(s) spoken Cell phone Your birth date Is it OK to Leave a voicemail? Yes No Email Referral source Referral date Intake Questions 1) Is this your first pregnancy? Yes No 1a) If no, how many children do you have and what are their ages? 1b) If no, were any of your children born: Low birth weight High birth weight Premature 2) Are you currently taking prenatal vitamins? Yes No 3) Are you or your baby of Aboriginal heritage? Yes No 4) Are you an immigrant or refugee to Canada? Yes No 4a) Country of origin? 4b) Number of years in Canada? 5) Are you married, common law, in a relationship, or a single parent? 6) Are there times that you cannot afford to buy enough food? Yes No 7) Are you or your partner unemployed or on income assistance? Yes No 8) Are you struggling with your current housing? (ex. eviction/not enough rooms) Yes No 9) During this pregnancy have you smoked cigarettes? Yes No 10) During this pregnancy have you used any drugs? Yes No 11) During this pregnancy have you drank any alcohol? Yes No 12) Do you currently have a doctor, midwife, or doula? Yes No 13) Any medical conditions that affect the pregnancy? (ex. diabetes/low iron) Yes No 14) Do you now, or have you ever had depression or anxiety? Yes No 15) In the last year has anyone tried to hurt you? (physical, sexually, emotionally) Yes No 16) Do you have any specific concerns about your nutrition? (ex. allergies/weight gain) Yes No 17) Do you have friends or family to support you during this pregnancy? Yes No Comments: Submit
