Confidential Patient Health Profile For The Pregnant Patient Form

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CONFIDENTIAL PATIENT HEALTH PROFILE FOR THE PREGNANT PATIENT
_________________________
Today’s Date:
Your answers will help us determine if our care can help you. If we do not sincerely believe your condition will
respond satisfactorily, we will not accept your case but will work to refer you to the appropriate health care
provider. If you need help with this form, please do not hesitate to ask.
PERSONAL INFORMATION
Name: Mrs. Ms Miss Dr. _______________________________________________________________________
Marital Status:
M
S
W
D
Alberta Health Care Number: _____________________________
Address: ____________________________________________________________ City: _________________________
Postal Code: ____________________ Home #: _______________________ Cell/Business #___________________
Date of Birth: dd______mm______yy________ Age: ______email address: _______________________________
Employer: ________________________________ Occupation: ____________________________________________
Hobbies (what occupies your spare time?)__________________________________________________________
Spouse or Partner’s name: ________________________________________________Children (#) ______________
How
did
you
hear
about
our
office
or
whom
may
we
thank
for
referring
you?
___________________________________________________________________________________________________
PREGNANCY INFORMATION
How many weeks pregnant are you? ________ When is your Due Date? _______________________________
Where is your birth to take place?
Home
Birthing Centre
Hospital
Any expected or current complications? (Breech presentation, placenta previa, gestational diabetes,
previous c-sections, hypertension etc.) ______________________________________________________________
___________________________________________________________________________________________________
Do you have Birth Support?
Midwife
Douala
neither
Do you have a Birth Plan in place?
Yes
No If No, why not?___________________________________
Are you involved in any Pre-natal Classes? (Bradley Method, HypnoBirthing, Birthing Within, CHR)
___________________________________________________________________________________________________
Are you taking part in any pre-natal fitness programs? ______________________________________________
Do you know the sex of the baby? __________
Do you plan to Breast Feed?
Yes
No
HEALTH INFORMATION
hat is your major complaint?
W
___________________________________________________________________________________________________
How long have you had this condition?
___________________________________________________________________________________________________
Have you had this or similar conditions in the past?
No
Yes, When?
___________________________________________________________________________________________________
What activities aggravate your condition?
___________________________________________________________________________________________________

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