Secure Client Intake Form
Your privacy is important to us. Thames Valley Midwives will not share or sell your information with anyone else.
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Your contact information
First and Last Name:
Street Address Line 1
Street Address Line 2
State / Province
Home phone number:
Cell phone number:
Work phone number:
Do you consent to Thames Valley Midwives using your email?
Name of your spouse/partner:
Name of doctor:
Weight (before getting pregnant):
Do you have a disability that requires special accommodation? If so please specify.
Date of first day of your last period:
Are your cycles regular?
How often are your periods? e.g. 28 days, 30 days
Previous pregnancy history
If you have been pregnant before, please answer the following: Please tell us about your pregnancies, including any miscarriages you have had and tell us how many pregnancies you have had:
Did you have any pre-term deliveries:
Did you ever deliver with the assistance of forceps or vacuum:
Did you ever deliver by cesarean section:
Did you have any medical complications in any pregnancy:
Did you have any complications in any delivery:
Did you ever deliver at home:
Current pregnancy information
Have you had an ultrasound this pregnancy?
Have you had bloodwork done by your doctor this pregnancy:
List of prescription medications you take:
Are you seeing any other medical professionals or professionals currently? i.e. family doctor, obstetrician, mental health practitioner, social worker, specialist. You can list multiple professionals.
Have you had a Midwife before:
What led you to contact Thames Valley Midwives:
Please do not call our office regarding this submission – we will contact you if and when a spot becomes available. In the meantime, please continue to see your family physician or your current care provider. You may also wish to contact other Midwifery groups in your area in order to place your information on their wait lists, as well. Thames Valley Midwives will only contact you if a spot becomes available.