Prenatal Nutrition Program Application

Date

Name of Applicant:

First Last

Name of Spouse:

First Last

Address

Street Address Address Line 2 City Province Postal Code

Phone

Applicant Birth Date:

Expected Due Date:

Date of 1st ultrasound?

Date of 2nd ultrasound?

Smoker?

Yes

Quit after discovery of pregnancy

How long did you quit smoking?

Prescription drugs?

Alcohol consumption?

Gestational Diabetes?

Special diet?

Any complications regarding pregnancy?

Family Doctor Name:

First Last

Family Doctor Phone Number:

In case of emergency, please contact:

Please list any allergies you or your child have:

Please list any medical conditions you or your child have:

All information given is confidential

Questions or concerns?
Please call Marion Primozic
(867)456-6888 ext. 320 or 332-5262

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Whitehorse Office

304 Jarvis Street

Whitehorse, YT Y1A 2H2

(867) 456-6888

Haines Junction Office

#1 Allen Place, P.O. Box 5310

Haines Junction, YT Y0B 1L0

(867) 634-4200

Community Buildings

Takhini Hall 667-6701

Da Ku Store 634-3307

Youth Center 634-2012

Mun Kų 634-7001

Champagne Hall 634-2336

Klukshu Hall 634-2342

[email protected]

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