Health History

london ontario midwives

talbotcreek midwives

Client Information and Health History

Please complete the health history form below prior to your intake appointment. If you are uncertain of any of questions, please leave them blank and we can complete at your first appointment. Filling out this questionnaire in advance of your appointment allows for more time for us to get to know you.

 

We are looking forward to meeting you!

 

- Your TCM Team

Health History Form

  • Patient Information

  • Partner Information

  • Medical Team

  • Pregnancy Summary

  • (the first day of bleeding)
  • (From the beginning of the first day of bleeding to the start of your next period- it is usually 28 days for most people)
  • (without the help of fertility treatments)
  • Pregnancy History

  • Have you had any of the following symptoms during this current pregnancy?

  • (dairy, dark green leafy vegetables)
  • (Foods you can’t eat or choose to avoid) If so, please list all of the foods you do not/ cannot eat.
  • Medical and Surgical History

  • (wisdom teeth, tonsils, adenoids, broken bones etc.)
  • (ie. very high body temperature, difficulty waking up from anesthesia, nausea, and vomiting)
  • Have you ever had any of the following issues?

  • (heart conditions, asthma)
  • (ie. Addisons disease, Graves disease, Hashimoto's, prolactinoma, and Cushing's Syndrome)
  • (irritable bowel, crohns, colitis)
  • (cysts, masses, cancer, or family history of breast cancer on your mother’s side)
  • (History of infertility, abnormal pap results, polycystic ovarian syndrome, ovarian cysts, uterine fibroids, endometriosis, heavy painful periods, colposcopy procedures, cervical polyps)
  • (painful joints, connective tissue disorders)
  • (brain issues, migraines, seizures)
  • Family Medical History

  • (i.e., diabetes, thyroid issues, high blood pressure, clotting/anesthetic or mental health conditions)
  • Have you ever been diagnosed with any of the following:

  • (past or currently - Gonorrhea, Chlamydia, genital herpes, genital warts or HPV, etc)
  • (Tay Sachs, cystic fibrosis, muscular dystrophy, sickle-cell disease, thalassemia, Downs Syndrome, other genetic conditions)
  • (Heart conditions, extra fingers, deafness and blindness etc.)
  • Mental Health

    Do you have a history of:
  • Lifestyle or Social History

  • (physical, emotional or sexual)
  • Medications

    Please list any of the following that you are currently taking:
  • If so, please list them all and the reaction that you get when you are exposed to these things:
  • Current Pregnancy

  • This field is for validation purposes and should be left unchanged.
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