GC - Intake Form

First Name

Last Name

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Are you a US or Canadian citizen?

State

Phone Number

Height

Weight (in pounds)

lbs

How did you hear about us?

Do you speak and understand English fluently?

Do you smoke?

Do you use nicotine in any form?

Do you use marijuana?

Have you used illicit drugs in the last 12 months?

Will you allow us to conduct a background check on you?

Do any of your own children live at home with you?

Are you currently taking any medication?

Have you previously had any surgery?

How many deliveries have you had?

How many pregnancies have you had? This includes miscarriages, stillbirths, live births.

How many c-sections have you had?

Have you been diagnosed with gestational diabetes in the past?

Have you been diagnosed with preeclampsia in the past?

Was your last pregnancy full term (37 weeks or more)?