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Screening Questionnaire
Cedar Midwifery Collective · Midwifery
First Visit
Follow-Up Visit
Your name
Email
Patient Information
First name
*
Last name
*
Date of birth
*
Health card number
Gender
— select —
Male
Female
Other
Prefer not to say
Preferred name
Preferred pronouns
Address
Phone
Email
Emergency Contact
Emergency contact name
*
Emergency contact relationship
Emergency contact phone
*
Emergency contact alternate phone
Primary Care Provider
Family physician
Family clinic
Family physician phone
Visit Information
Reason for visit
*
— select —
First Visit
Follow-up
Annual Physical
Dental Cleaning
Dental Emergency
Hospital Admission
Hospital Follow-up
Specialist Referral
Laboratory Test
Diagnostic Imaging
Vaccination
Prescription Renewal
Current Symptoms
Which symptoms are you experiencing today? (select all that apply)
Fever
Chills
Cough
Sore throat
Runny nose
Headache
Chest pain
Shortness of breath
Abdominal pain
Vomiting
Diarrhea
Nausea
Dizziness
Weakness
Rash
Swelling
Joint pain
Bleeding
Vision changes
Hearing changes
Symptom severity
— select —
Mild
Moderate
Severe
Infectious Disease Screening
Any of these exposures or infections? (select all that apply)
COVID exposure
Influenza symptoms
RSV exposure
Tuberculosis exposure
Measles exposure
Chickenpox exposure
C. difficile history
MRSA history
VRE history
Recent international travel
Infection Control
Are you currently sick?
*
Yes
No
Do you have a fever today?
*
Yes
No
Do you have a productive cough?
Yes
No
Difficulty breathing?
Yes
No
Loss of smell or taste?
Yes
No
Vomiting?
Yes
No
Diarrhea?
Yes
No
Skin infection?
Yes
No
Open or draining wound?
Yes
No
Medical History
Do you have any of these conditions? (select all that apply)
Hypertension
Diabetes
Heart disease
Stroke
Asthma
COPD
Kidney disease
Liver disease
Cancer
Thyroid disease
Osteoporosis
Arthritis
Seizure disorder
Dementia
Depression
Anxiety
Bipolar disorder
PTSD
Surgical History
Previous surgeries (with dates)
Procedure, date, and any complications
Previous hospitalizations
Allergies
Do you have allergies to any of these? (select all that apply)
Drug allergies
Food allergies
Latex
Adhesive
Contrast dye
Other
Please list your allergies and details
Type of reaction
— select —
Rash
Hives
Swelling
Anaphylaxis
Unknown
Medications
Current medications (name, dose, frequency)
Prescribing physician
Supplements / natural products
Do you take blood thinners?
Yes
No
Do you take insulin?
Yes
No
Family History
Family history of (select all that apply)
Heart disease
Diabetes
Cancer
Stroke
Mental illness
High blood pressure
Kidney disease
Genetic disorders
Social History
Smoking status
— select —
Never
Former
Current
Alcohol use
— select —
None
Occasionally
Weekly
Daily
Cannabis use
Yes
No
Recreational drug use
Yes
No
Occupation
Living arrangement
Exercise frequency
Diet
Mental Health Screening
Past mental health diagnosis
Yes
No
Current stress level
— select —
Low
Moderate
High
Are you feeling depressed?
Yes
No
Are you feeling anxious?
Yes
No
Sleep problems?
Yes
No
Memory concerns?
Yes
No
Any suicidal thoughts?
*
If yes, staff will follow up immediately.
Yes
No
Currently in counseling?
Yes
No
Pain Assessment
Are you in pain today?
Yes
No
Pain location
Pain duration
Pain scale (0–10)
0
10
0
Pain quality
— select —
Sharp
Burning
Throbbing
Radiating
Vaccination Status
Which vaccinations are up to date? (select all that apply)
COVID
Influenza
Tetanus
Hepatitis
MMR
Varicella
Pneumococcal
Shingles
HPV
Travel Screening
Have you visited another country recently?
Yes
No
Which country?
Travel date
Exposures during travel (select all that apply)
Animal exposure
Insect bites
Water exposure
Accessibility
Accessibility needs (select all that apply)
Interpreter needed
Wheelchair access
Vision impairment
Hearing impairment
Language preference
Financial / Insurance
Insurance / coverage (select all that apply)
Private insurance
WSIB
Motor vehicle insurance
Veteran
Refugee coverage
NIHB
Consent
Consent to treatment
*
Yes
No
Consent to collect health information
*
Yes
No
Consent for SMS
Yes
No
Consent for email
Yes
No
Consent for appointment reminders
Yes
No
Consent to share information
Yes
No
Midwifery Screening
Expected due date
Number of previous pregnancies
Number of miscarriages
Previous cesarean
Yes
No
High-risk pregnancy
Yes
No
Gestational diabetes
Yes
No
High blood pressure
Yes
No
Are you feeling baby movements?
Yes
No
Any bleeding?
*
Yes
No
Any contractions?
Yes
No
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