About this template
This comprehensive Midwifery Client Intake & Medical History Form is designed for licensed midwives, birth centers, and home birth practices. Collecting thorough health data is vital for ensuring safe, personalized prenatal and postnatal care. This form streamlines the onboarding process by securely gathering essential client details, partner information, insurance data, past medical and surgical history, gynecological background, and detailed obstetrical records.
Built for modern midwifery practices, this template replaces cumbersome paper packets with a structured digital format that parents can complete from home. It captures critical clinical insights—such as previous pregnancy outcomes, allergies, current medications, mental health history, and birth preferences—giving care providers a complete picture before the initial consultation. Utilizing Doc2Form, you can instantly turn this structured data collection into a ready-to-use Google Form, ensuring a seamless experience for both your practice and your growing families.
Key features
- Collect complete medical and obstetric history in a single digital flow
- Gather essential insurance and emergency contact details upfront
- Document previous pregnancy outcomes, labors, and complications
- Assess home birth readiness, support systems, and personal preferences
- Easily customize sections to fit your specific practice guidelines
Use cases
- New client onboarding for home birth midwifery practices
- Initial prenatal health and medical history assessments
- Gathering birth desires and postpartum support plans
- Pre-consultation screening for prospective midwifery clients
What this form collects
- Client Full Name (Short answer)Enter your first, middle, and last name as it appears on official documents.
- Client Preferred Name (Short answer)What name would you like us to use when addressing you?
- Home Address (Paragraph)Street address, city, state, and ZIP code where you currently reside.
- Primary Phone Number (Short answer)Best number to reach you during the day.
- Email Address (Short answer)We will use this email to send appointment reminders and educational resources.
- Date of Birth (Date)MM/DD/YYYY
- Emergency Contact Full Name (Short answer)Name of a trusted friend or family member to contact in an urgent situation.
- Emergency Contact Phone Number (Short answer)Direct phone number for your emergency contact.
- Emergency Contact Relationship (Short answer)E.g., Partner, Parent, Friend
- Payment Method / Insurance Provider (Dropdown)Select your primary insurance provider or payment plan type.
- Insurance ID Number (Short answer)Enter your member ID or policy number.
- Blood Type (Short answer)If known (e.g., A positive, O negative, Unknown).
- Allergies and Sensitivities (Paragraph)List any known allergies to medications, foods, latex, or environmental factors, along with your reaction.
- Current Medications and Supplements (Paragraph)List any prescription drugs, over-the-counter medicines, herbs, and vitamins you currently take.
- Past Medical Diagnoses & Surgeries (Paragraph)Briefly describe any significant past medical conditions, hospitalizations, or surgeries.
- Number of Pregnancies (Gravida) (Short answer)Total number of times you have been pregnant, including the current pregnancy.
- Number of Children Now Living (Para) (Short answer)Total number of living children.
- Previous Pregnancy Complications (Paragraph)Describe any complications or unusual events in past pregnancies, labors, or postpartum periods.
- First Day of Last Period (LMP) (Date)MM/DD/YYYY
- Ultrasound Estimated Due Date (Date)MM/DD/YYYY, if established by an early ultrasound.
- Have you seen another provider for this pregnancy? (Multiple choice)Select one.
- What are your primary goals and desires for this birth? (Paragraph)Share what matters most to you, your support team, and your ideal birth environment.
- Do you feel fully supported by your family and friends in your choice of care? (Paragraph)Describe any concerns or strong support systems you have in place.
FAQ
Can I add or remove questions from this template?
Yes. Once generated in your Google Drive, you have full control to edit, add, or remove any questions using the standard Google Forms editor.
Is this template suitable for birth centers as well as home birth practices?
Absolutely. While it covers home birth safety and readiness, the core medical, gynecological, and obstetrical history sections are ideal for any midwifery-led care model.
How do clients access this form?
You can share the Google Form link directly via email, embed it on your practice website, or send it as part of your welcome packet automation.
Are the responses secure?
Responses are saved securely in your Google Workspace account linked to Google Drive, allowing you to manage permissions according to your practice's privacy standards.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.