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?
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

Other
Do you have a family history of any of the following

Other
Have you ever had a procedure performed on your cervix?
Have you ever injured your tailbone?
Have you ever injured your pelvis?
Which of the following describes your current level of physical activity?
Do you currently see a chiropractor, massage therapist or other bodyworker?

Other
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?
Are you aware that labor and birth do not follow a specific timeline? The labor process may last anywhere from 2 - 40+ hours.
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!
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.
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.
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.
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