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English
BARRIE MIDWIVES
Demographics
*
Legal first name
*
Legal last name
Preferred name
Personal Pronouns
*
Applicant's date of birth
*
Street Address
*
City
*
Postal Code
*
Email address
*
Primary Phone
Secondary Phone
*
Are you covered by OHIP?
Yes
No
I don't know
Health Card Number
Health Card Version Code
Applicant's Health Information
Are you on medication?
Yes
No
Prefer not to answer
Do you have any medical complications?
Yes
No
Prefer not to answer
*
Do you have a Family Doctor?
Yes
No
Are your cycles 28 days regular?
Yes
No
Prefer not to answer
*
What was the
first
day of your most recent period?
Have you had an ultrasound in this pregnancy?
Yes
No
*
Where are you planning to give birth?
Home
Royal Victoria Regional Health Centre (RVH)
Undecided
Other
Is there a midwife you would like involved in your care?
Yes
No
Is there anything else you'd like to tell us about your current pregnancy or birth plan?
Previous Birth History
Have you used midwives before?
Yes
No
*
How many times have you been pregnant? (including this pregnancy)
Next
