Patient Information Name (As It Appears On Your Health Card) *
Preferred Name (If Different) What is your current address? How old will you be when your baby is born? What is your identified ethnicity? What is your highest level of education? If you are employed, what is your job title? Relationship Status: What is your first language? Do you speak English? Do you have a disability that requires a special accommodation? What is your sexual orientation? Do you know about the option for genetic screening? Please select the statement(s) that best apply to you: Partner Information Do you have a partner? If you have a partner, what is their first and last name?
What is your partner's phone number in case of emergency? What is your partner's identified ethnicity? What is your partners occupation? What is their highest level of education? How old is your partner? Medical Team Do you have a family doctor? If you have a family doctor, what is their name? Where would you like to give birth? Pregnancy Summary When was the first day of your last menstrual period?
(the first day of bleeding)
Are you certain about this, or can’t remember? Were your period cycles regular? How far apart were your periods?
(From the beginning of the first day of bleeding to the start of your next period- it is usually 28 days for most people)
If you have been given a due date for this pregnancy, please provide it here: Were you using contraception or birth control within 3 months of getting pregnant? If so, what kind were you using? Was your current pregnancy planned? Is this a surrogate pregnancy? Did you conceive this pregnancy spontaneously?
(without the help of fertility treatments)
If you were receiving fertility care, which clinic did you attend and what is the name of your fertility doctor? If this is a pregnancy conceived through in-vitro fertilization, what was the date of transfer of the embryo? Was this a 3 or 5 day transfer? Pregnancy History How many total pregnancies have you had? How many were born before 37 weeks pregnant? How many miscarriages or terminations have you had? Have you had any of the following symptoms during this current pregnancy? Vaginal bleeding? Nausea/Vomiting? Rash/Fever or Illness? Have you been diagnosed with COVID-19 in the past year? Do you eat/consume enough calcium in your diet currently or before pregnancy?
(dairy, dark green leafy vegetables)
Do you take vitamin D? Did you take folic acid prior to getting pregnant? Are you currently taking a prenatal vitamin? Would you say you have a balanced diet, with regular daily protein and fruit/vegetable intake? Do you have any dietary restrictions, and if so, please list them and the reaction you get when you eat them
(Foods you can’t eat or choose to avoid) If so, please list all of the foods you do not/ cannot eat.
Pregnancy is an important time to discuss diet, exercise and weight gain - is this something we can discuss in your prenatal appointments? Do you exercise? If so, please describe exercise you do prior to pregnancy and/or currently: Are you looking for more information about diet and exercise in pregnancy? Medical and Surgical History Have you ever had surgery?
(wisdom teeth, tonsils, adenoids, broken bones etc.)
If so, please list which surgeries you have had, the year you had them, and whether you had any complications from the surgeries: Have you ever had a problem with general anesthetic (being put to sleep for surgery)?
(ie. very high body temperature, difficulty waking up from anesthesia, nausea, and vomiting)
Have you ever had a family member who has had a bad or negative reaction during a general anesthetic or while being put to sleep? If so, what was their reaction to the anesthetic? Have you ever had any of the following issues? High blood pressure? Heart or lung issues?
(heart conditions, asthma)
Endocrine (thyroid, diabetes), or hormonal problems?
(ie. Addisons disease, Graves disease, Hashimoto's, prolactinoma, and Cushing's Syndrome)
Gastrointestinal/ liver problems?
(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)
Urinary tract infections? Musculoskeletal/Arthritis issues?
(painful joints, connective tissue disorders)
Blood/ bleeding/Clotting disorders? Deep vein thrombosis, pulmonary embolism? Blood transfusions? If so, when and for what reason? Neurological conditions?
(brain issues, migraines, seizures)
Are there any other reasons you have been hospitalized in the past? Is there anything else about your medical history that we should know? Family Medical History Does your family have a history of medical conditions?
(i.e., diabetes, thyroid issues, high blood pressure, clotting/anesthetic or mental health conditions)
If so, who? Have you ever had chicken pox? Have you received the chicken pox (varicella) vaccine? Have you ever been diagnosed with any of the following: Human immunodeficiency virus (HIV)? Herpes Simplex Virus (HSV)- cold sores or genital herpes/sores? Has your partner been diagnosed with HSV (cold sores or genital herpes/sores) Have you had any other sexually transmitted infections?
(past or currently - Gonorrhea, Chlamydia, genital herpes, genital warts or HPV, etc)
Have you ever been diagnosed with hepatitis C, tuberculosis (TB), parvovirus (fifths disease/ slapped cheek syndrome) or toxoplasmosis? Have you been diagnosed with any other infectious diseases not listed above? Do you or your partner have anyone born in their family with any of the following conditions:
(Tay Sachs, cystic fibrosis, muscular dystrophy, sickle-cell disease, thalassemia, Downs Syndrome, other genetic conditions)
If you answered yes to the last question, what is the condition? Have you or your partner, or any family member been born with any physical conditions or abnormalities?
(Heart conditions, extra fingers, deafness and blindness etc.)
Is it possible that you and your partner could be related? Have you been offered or already completed genetic screening to assess your risk for having a child born with Downs Syndrome, or other genetic conditions? If so, which screen or test did you have? Mental Health
Do you have a history of:
Anxiety? Depression? If so, have you previously or are you taking medication(s) for any of these conditions? If so, which medication(s)? Eating Disorder(s)? Bipolar Disorder? Schizophrenia? Other personality disorders? Are you currently experiencing symptoms of anxiety or depression? Have you smoked a cigarette in the previous 6 months? Are you drinking alcohol now that you are pregnant? When was your last drink of alcohol? Are you smoking or vaping marijuana now that you are pregnant? Are you taking non-prescribed substances or drugs? Lifestyle or Social History Are you exposed to any unsafe behaviours/people or environmental hazards at your job? Do you have any financial concerns including housing stability? Do you have enough social supports for your pregnancy? Do you have any religious or cultural practices that may impact your pregnancy, birth, or newborn care? Or any practices/ beliefs that you want us to be aware of? Do you have any concerns around your relationship with your partner? Do you have any concerns about domestic abuse, past or present?
(physical, emotional or sexual)
Do you have any concerns related to the physical or emotional aspects of childcare? Do you have any other concerns about your lifestyle/social activities with regard to pregnancy/newborn care? Medications
Please list any of the following that you are currently taking:
Medications (prescription or over the counter medications): Vitamins: Supplements: Do you see a naturopathic doctor, osteopath, chiro or any other alternative care provider? Do you have any allergies/ intolerances or sensitivities?
If so, please list them all and the reaction that you get when you are exposed to these things:
Current Pregnancy How tall are you? What is your pre-pregnancy weight? When was your last pap test? Were the results normal? Are you having twins? Have you had bloodwork done in the pregnancy so far? Have you had any ultrasounds in the pregnancy so far, and if so, where did you have them done? How many weeks pregnant were you at the time of your first ultrasound? CAPTCHA Phone
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