Please submit this form before our first prenatal meeting. Thanks so much and looking forward to working with you! Intake Form Intake Form Name First Name Last Name Partner's Name First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Client's Phone Number (###) ### #### Partner's Phone Number (###) ### #### Estimated Due Date MM DD YYYY Care Provider First Name Last Name Birthing Location Birthing Location Address Address 1 Address 2 City State/Province Zip/Postal Code Country Allergies? (Food/Medication) Please list any medical conditions prior to conception that would impact pregnancy or birth. Any Medical conditions Developed During Pregnancy: None Gestational Diabetes Group B Strep Severe Insomnia Anxiety Depression Hyperemesis Gravidarum Anemia Heartburn Headaches Pica Back Injury/Pain Preeclampsia How much and how well are you sleeping during this pregnancy? What number pregnancy is this for you? Number of Previous Births: Please list the number of living children and their ages Please describe your physical and emotional prenatal and pregnancy experience so far: Have you taken a childbirth education class? Please list date and location. What is your birth vision? If things go perfectly according to this vision, describe what this looks and feels like for you. Have you made a birth plan? Yes No During early labor, when does your medical provider want you to call them? Have you discussed protocols with your care provider if you go past your estimated due date? Please describe any activities you have been doing to physically/emotionally prepare for your birth. (ex. meditation, exercise, etc.) What do you think will be your greatest challenge for this pregnancy/birth/postpartum experience? Do you have any persistent concerns/fears regarding your birth? What do you think will be your greatest strength for your pregnancy/birth/postpartum experience? Please check any pain management or relaxion techniques that you would NOT like to use. Aromatherapy Directed Breathing Heating pad Ice packs Massage Counterpressure/hip squeezes Any other techniques you would like to try? In what ways do you hope a doula's support will be helpful for you? What types of assistance do you imagine will be most useful for you? How does your partner/support person want to be involved in your birth? I.e. Hands on, share support with doula, or let the doula take the lead. Photography/video planned? Specifics? Any special requests? (items to bring, role with relatives, etc.?) Infant Feeding Breastfeeding Bottle: Human milk Bottle: Formula What should I NOT do or say? Please share anything else you would like me to know about you or any topics you would like to discuss. Thank you!
