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Midwifery care >
Pregnancy ultrasounds >
Mom & Baby Spa
About us >
Rates
Get in touch
Sign up

Intake form

This form contains questions to help prepare for the intake appointment. Please complete all questions. During the intake appointment, the questions will be reviewed and further explanation can be given.

"*" indicates required fields

First name*

Middle name

Last name*

Date of birth*

DD dash MM dash YYYY

Email address*

Where were you born?*

What is your background?*

Where are your parents from?

What is your occupation?*

What was your weight and height before the pregnancy?*

What is the name of your GP’s health centre?*

Do you give permission for us to request your medical records from your GP?*

We will determine which information is relevant to the pregnancy and will always discuss this with you.

Ja

Nee

What is your marital status?*

Living together

Single

Married

Registered partnership

Living apart together

Is there a religion we may record?*

Do you already have a child?*

Yes

No

We would like to know when the child was born, their name, birth weight, and at how many weeks of pregnancy. Were there any special circumstances? Did you give birth vaginally or by caesarean section?

Have you had surgery before?*

Yes

No

What surgery did you have?

Please state in which hospital and whether there were any complications.

May we request these records?

Yes

No

Have you ever received a blood transfusion?*

Yes

No

Do you have any heart, lung, brain, or blood clotting problems?*

Yes

No

Do you have an allergy?*

Yes

No

Please fill in which allergy/allergies you have and describe your symptoms.*

Does diabetes occur in your father, mother, brother, or sister?*

Yes

No

Does hypertension occur in your father, mother, brother, or sister?*

Yes

No

Do thyroid disorders occur in your father, mother, brother, or sister?*

Yes

No

Have you had a bladder infection before?*

1 to 5 times

5 to 10 times

10+

Not applicable

Have you had a vaginal yeast infection before?*

1 to 5 times

5 to 10 times

Not applicable

Do you smoke?*

Yes

No

Do you drink alcohol?*

Yes

No

Do you use drugs?*

Yes

No

Have you recently, or some time ago, stopped smoking, using drugs, or drinking alcohol?*

Yes

No

When did you stop?

Did you have chickenpox as a child?*

Yes

No

I don’t know

Did you receive childhood vaccinations, such as DTP?*

Yes

No

I don’t know

Are you currently, or have you previously been, under the care of a psychologist?*

Please fill in whatever you feel comfortable sharing.

Have you had a vaginal smear test before?*

Yes

No

In case of an abnormal PAP smear result: was a conisation performed?*

Yes

No

Where did the treatment take place?

May we request these records?

Yes

No

Do you take medication?*

Yes

No

Which medication do you take?*

Which of the following supplements do you use?*

Folic acid

Vitamin D

Pregnancy multivitamin

Other

Other, namely

Are you under the care of a specialist?*

Yes

No

Have you had a cold sore before?*

Yes

No

Maybe

Do you have a partner?*

Yes

No

Is your partner healthy?*

Yes

No

Explanation

Does your partner smoke?*

Yes

No

Has your partner had a cold sore before?*

Yes

No

What is your partner’s occupation?

Are there any important matters we have not asked about?*

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