Pre-Birth Service
Initial Maternal/Fetal Assessment Checklist
The information that you give helps your health care team to personalize your care during your pregnancy,
delivery and postpartum experience. The content of this form will be shared only with other health care
providers. Please answer the following questions before your registration appointment and bring it with
you.
Name:
Due Date:
Name of Family Doctor/Registered Midwife/Nurse
Practitioner:
Obstetrician:
Allergies:
Please explain reaction:
How many pregnancies have you had including this one?
What is your country of birth?
How many live births have you had?
How long have you lived in Canada?
Do you need an interpreter?
 no
 yes
Interpreter name and contact information:
What languages do you speak?
What languages do you read?
Do you have any religious/cultural concerns or practices related to your pregnancy or the birth of
your child that you want us to know about to help with your care?
 no
 yes
If yes, please explain:
Have you ever taken prenatal classes?
Have you received prenatal care for this
 0 – 2 sessions
pregnancy before today?
 3 or more sessions
 no
 yes
When was the first prenatal visit?
Date:_____________
How many years of school have you
How many cigarettes do you smoke every day?
completed?
0
 0 to 7 years
 1 to 5
 8 years to less than high school diploma
 6 to 10
 High school diploma
 11 to 15
 College/University - no degree
 16 to 20
 College/University - degree or more
 Over 20
If you would like help to quit smoking please contact your primary health care provider or the
Smoker’s Helpline at 1-877-513-5333 or visit www.smokershelpline.ca
Do you wear:
Do you have trouble
 Other (e.g. disabilities)
 glasses  contacts  none
hearing?  yes  no
What was your weight before you became
What is your present
How tall are you?
GRH1828 (10/10)
pregnant?
weight?
Do you have any food allergies, special dietary needs or intolerances?
 no
 yes
If yes, please describe how they affect you:
What food do you eat everyday?
 Fruits/Vegetables
 Grains
 Milk Products
 Meats/Alternatives (legumes)
Are you a vegetarian?  no
 yes
If yes, what do you not eat?
Have you had, or do you have an eating disorder?
 no
 yes
If yes, please explain:
Do you have any concerns about your eating patterns? (e.g. heartburn, nausea, vomiting, other)
 no
 yes If yes, please explain:
Do you or the father of the baby have any genetic health problems in your immediate family? (e.g.
deafness)  no
 yes If yes, please explain:
Please check any problems you may have had in the past or with this pregnancy.
 Medical concern
 Anxiety disorder
 Depression  Postpartum Mood Disorder (PPMD)
Please describe:
Do you have any concerns about the following:
 Finances
 Housing
 No support at home
Please describe:
 Relationship issues, personal safety
Please check if you would like to speak to any of the following health care providers:
 Hospital Nurse
 Public Health Nurse
 Social Worker
 Dietitian
What medications/over-the-counter medications, vitamins, herbal remedies do you take? Please
list the details in the space below.
Name
The amount taken?
How often taken?
How do you take it?
Please list any other questions or concerns that you may have about your pregnancy, labour and
delivery and/or postpartum experience.
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Signature ______________________________
Date: __________________________