Healthiest Babies Possible

Client Information
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Intake Questions
1) Is this your first pregnancy?
1b) If no, were any of your children born:
2) Are you currently taking prenatal vitamins?
3) Are you or your baby of Aboriginal heritage?
4) Are you an immigrant or refugee to Canada?
6) Are there times that you cannot afford to buy enough food?
7) Are you or your partner unemployed or on income assistance?
8) Are you struggling with your current housing?
(ex. eviction/not enough rooms)
9) During this pregnancy have you smoked cigarettes?
10) During this pregnancy have you used any drugs?
11) During this pregnancy have you drank any alcohol?
12) Do you currently have a doctor, midwife, or doula?
13) Any medical conditions that affect the pregnancy?
(ex. diabetes/low iron)
14) Do you now, or have you ever had depression or anxiety?
15) In the last year has anyone tried to hurt you?
(physical, sexually, emotionally)
16) Do you have any specific concerns about your nutrition?
(ex. allergies/weight gain)
17) Do you have friends or family to support you during this pregnancy?

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