Client Intake Mama's Name * First Name Last Name Mama's Phone (###) ### #### Email * Parter / Support Person's Name * First Name Last Name Partner / Support Person's Phone * (###) ### #### Emergency Contact * (specify relationship) First Name Last Name Estimated Due Date * MM DD YYYY Care Provider Birthing Location * Birthing Location Address Address 1 Address 2 City State/Province Zip/Postal Code Country Have you taken a tour of your birthing place? (if applicable) Yes No I plan to Any Food/Medication Allergies? (specify for both partners) Please list any medical conditions prior to conception that could impact pregnancy or birth. Any Medical Conditions Developed During Pregnancy: * None Gestational Diabetes Group B Strep Severe Insomnia Anxiety Depression Hyperemesis Gravidarum (severe morning sickness) Anemia Heartburn Headaches Pica Back Injury/Pain Preeclampsia Other: 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 (or do you plan to take) a childbirth education class? Please list date and location. Please check any topics you would like more information on:: Ways labor can begin Early labor signs and signals Stages of labor Timing and contractions Natural comfort strategies/pain management Breathing Techniques Positions for Labor Unmediated/Medicated Labor and Birth Unmediated/Medicated Inductions Common medical procedures in labor Pain medications/medical interventions in labor Positions for pushing Episiotomy Assisted vaginal delivery Cesarean Delivery Post-birth procedures Newborn procedures Postpartum healing Postpartum support planning Breast feeding Newborn care Postpartum mood disorders Postpartum nutrition Other: Are you and/or your partner/support person reading and books on pregnancy/childbirth/postpartum or breastfeeding. Please list below. Do you have a postpartum support plan? (if not, we can make one together!) Postpartum Support Team Partner Family Postpartum Doula Lactation Support Friends Have you made a birth plan? (If not, we can do this together) Have you shared your birth plan/preferences with your medical provider? 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.) Have you packed a birth bag? (If no, we can do this together.) 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? In previously painful or emotionally intense situations (illness, injury, surgery) what have you found comforting? Please check any pain management or relaxation techniques that you would NOT like to use. Check those you DO NOT have interest in Massage Aromatherapy Acupressure points Meditation Guided Breathing Visualization Rebozo Heating Pad Music Therapy / Sound Bowls Please list any other techniques you would like to try: In what ways do you hope a doula's support will be helpful to 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. Please share anything else you would like me to know about you or any topics you would like to discuss. Thank you! I will see you soon for your first prenatal appointment.
