Best Beginnings program provides public health services to pregnant women, new moms, babies and children to age 2. Complete this 5-minute form to get connected with resources and supports for a healthy pregnancy and baby.

What happens after I register?

What Happens After I Register?

1

The information you provide becomes part of your confidential medical record.
2

Your completed form will be reviewed by a public health nurse.
3

You will receive a prenatal package with helpful health information and resources for your pregnancy.
4

You may receive a call from a public health nurse to connect you with community services and supports.
5

If you are having trouble completing the form or would like to ask a question or speak to a Public Health Nurse – please contact your local health unit.
 
 
Page 1 of 6

Your Pregnancy

Today's Date
22 October 17
Birth Date
Your Age
 
What is your due date?
How many weeks pregnant are you?
Calculated automatically using today's registration date and your baby's due date
 
With this baby, will you be a first time parent?
Page 2 of 6

Your Name and Contact Information

Name

Street Address
City
Postal Code
Phone Numbers
Please enter in the format ###-###-####
Which phone number is best to reach you at?
Is it okay to leave a message on your phone?
Your Email Address
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Page 3 of 6

Your Health Care Team

Name of Doctor or Midwife
Clinic Name (if applicable)
City of Doctor or Midwife
Phone # of Doctor or Midwife (Optional)
How many months pregnant were you at your first prenatal doctor or midwife visit?
Care Card Number (OPTIONAL)
Name of hospital where you plan to deliver your baby
Are you attending, or do you plan to attend prenatal education classes? (Optional)
Are you attending any of the following pregnancy support programs?
If yes, please check the appropriate box(s) below
 




prev NEXT REVIEW
Page 4 of 6

Information About You

How long have you lived in Canada?
Did you come to Canada as a refugee?
Do you need an interpreter?
If you need an interpreter what language do you speak?
Do you identify as having an Aboriginal Heritage (eg First Nations, Metis or Inuit)?
Have you completed high school?
prev NEXT REVIEW
Page 5 of 6

Information About You

Do you have someone you can talk to when you are upset or worried or just need to talk?
Do you have someone who can help you out with transportation, housing, childcare or other personal needs?
Are you finding it very difficult to live on your total household income?
Do you receive income assistance (e.g., disability, income assistance, employment insurance) or BC Medical Premium assistance?
prev NEXT REVIEW
Page 6 of 6

Information About You

During the past month have you often been bothered by feeling down, depressed or hopeless?
During the past month have you often been bothered by little interest or pleasure in doing things?
Please tick ONE of the options about tobacco
How often do people smoke around you?
Are you planning to breastfeed your baby? (Optional)
PREV REVIEW

REVIEW

Page 1

— YOUR NAME AND CONTACT INFORMATION EDIT


Birth Date
What is your due date?
How many weeks pregnant are you?
Calculated automatically using today's registration date and your baby's due date
With this baby, will you be a first time parent?

Page 2

— YOUR NAME AND CONTACT INFORMATION EDIT


Name
Street Address
City
Postal Code
Phone Numbers
Home   Cell
Is it okay to leave a message on your phone?
Which phone number is best to reach you at?
Your Email Address

Page 3

— YOUR HEALTH CARE TEAM EDIT


Name of Doctor or Midwife
Clinic Name (if applicable)
City of Doctor or Midwife
Phone # of Doctor or Midwife (Optional)
How many months pregnant were you at your first prenatal doctor or midwife visit?
Care Card Number (OPTIONAL)
Name of hospital where you plan to deliver your baby
Are you attending, or do you plan to attend prenatal education classes? (Optional)
Are you attending any of the following pregnancy support programs?
If yes, please check the appropriate box(s) below
Other. Please list...

Page 4

— INFORMATION ABOUT YOU EDIT


How long have you lived in Canada?
Did you come to Canada as a refugee?
Do you need an interpreter?
If you need an interpreter what language do you speak?
Do you identify as having an Aboriginal Heritage (eg First Nations, Metis or Inuit)?
Have you completed high school?

Page 5

— INFORMATION ABOUT YOU EDIT


Do you have someone you can talk to when you are upset or worried or just need to talk?
Do you have someone who can help you out with transportation, housing, childcare or other personal needs?
Are you finding it very difficult to live on your total household income?
Do you receive income assistance (e.g., disability, income assistance, employment insurance) or BC Medical Premium assistance?

Page 6

— INFORMATION ABOUT YOU EDIT


During the past month have you often been bothered by feeling down, depressed or hopeless?
During the past month have you often been bothered by little interest or pleasure in doing things?
Please tick ONE of the options about tobacco
How often do people smoke around you?
Are you planning to breastfeed your baby? (Optional)

Note: Additional registration may be required at your hospital.
Visit bestbeginnings.fraserhealth.ca for details.

SUBMIT