Barrie Midwives

Demographics

^*Legal first name

^*Legal last name

Preferred name

Personal Pronouns

^*Applicant's date of birth

^*Address

Apartment/suite, P.O Box, etc.

^*City

Province

Postal code

^*Email

Notifications will be sent to this address

Does not have an email address

^*Primary Phone

Secondary Phone

^*Are you covered by OHIP?

Yes

No

I don't know

Health Card Number

Version Code

Applicant's Health Information

^*Are you on medication?

Yes

No

^*Do you have any medical complications?

Yes

No

^*Do you have a Family Doctor?

YesNo

^*Are your cycles 28 days regular?

Yes

No

^*What was the first day of your most recent period?

Have you had an ultrasound in this pregnancy?

YesNo

^*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?

YesNo

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?

YesNo

^*How many times have you been pregnant? (including this pregnancy)

Midwifery Care

Demographics

Applicant's Health Information

Previous Birth History