Midwifery Client Intake Form

Client Information

Please complete this form in its entirety. Your responses will be forwarded to the midwife for reference during your consultation.
Your Name*
Partner's Name*
Due Date*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number(s)*
Include partner's phone number
E-mail Address*
Are you currently under the care of any type of physician?*
Current maternity care provider (type N/A if none)
Will this be your first home birth?

YesNo
Health History

We believe every woman strives to be her healthiest self during pregnancy. The following questions will alert your midwife of any factors that may impact your birth.
Your age*
Select any conditions that you have experienced, currently or in the past*

High blood pressurePreeclampsia or ToxemiaHELLP SyndromeType 1 DiabetesGestational DiabetesLow plateletsScoliosisFibroids,Blood disorderThyroid disorderAnemiaAsthmaFybromyalgiaHyperemesis GravidariumCholestasisSpinal surgeryHistory of preterm laborIncompetent cervixInfertilityDepression, anxiety or psychosisNone of the above
Do you have a family history of any of the following*

Hypertension/high blood pressureType 1 diabetesType 2 diabetesBlood disorderHeart defectsAnemiaGenetic abnormalitiesNone of the above
Have you ever had a procedure performed on your cervix?*

YesNoUnsure / Let's discuss
Have you ever injured your tailbone?*

YesNoUnsure / Let's discuss
Have you ever injured your pelvis?*

YesNoUnsure / Let's discuss
Which of the following describes your current level of physical activity?

Not very activeModerately activeExtremely active
Do you currently see a chiropractor, massage therapist or other bodyworker?

ChiropractorMassage TherapistBothNo
Birth Goals

Tell us what you have in mind for this birth.
Have you given birth before? If so, please describe your birth(s).*
Please disclose number of births, medicated/unmedicated, cesarean, fast labor, induction... here
Tell us about any tools you're currently using to prepare for the upcoming birth (i.e. books, classes, videos, podcasts, etc.)*
Birth Expectations & Vision

Please respond to the following:
Birthers (especially first baby and first VBAC) greatly benefit from having doula support. Are you currently working with a doula, or are you interested in having a doula at your birth?*

I have a doulaI want a doulaNot interested in doula servicesUnsure / Let's discuss
Are you aware that labor and birth do not follow a specific timeline? The labor process may last anywhere from 2 - 40+ hours.*

YesNoLet's discuss
While home is typically a more comfortable environment than the hospital, are you aware that labor can still be very hard work? Home birth does not always equal easy birth!*

YesNoLet's discuss
The midwife provides medical care and is responsible for facilitating a safe home birth. Comfort measures and emotional support during labor are the roles of a doula.*

YesNoLet's discuss
Are you aware that water birth is an option but can not be guaranteed? Water birth is an excellent option when labor is progressing smoothly but there are times when birthing on land is best.*

YesNoLet's discuss
Are you aware that a home birth outcome can not be guaranteed? If the health and safety of mom or baby are in question, hospital transfer will be recommended.*

YesNoLet's discuss
Are there any details that you would like to share about you, your family, your birth vision and/or your baby?
Are there any specific concerns you would like to share about this pregnancy and/or birth?
Should be Empty:

Client Information

Health History

Birth Goals

Birth Expectations & Vision