Intake Form

1
Congratulations on your pregnancy! Thank you for taking the time to fill out this form so I can get to know you better and have an idea of how I can best support you during your pregnancy, birth and postpartum! Should you have any questions please feel free to text me at 682-227-4379. I can call you and walk you through the questions via videophone. Thank you! - Salerno
2
Pregnant Person's Preferred Language?* This field is required.Check all that apply
American Sign Language
English
SEE/PSE
Other
3
Pregnant Person's Name* This field is required.
First Name
Last Name
4
Your Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Pregnant Person's Email* This field is required.
6
Pregnant Person's VideoPhoneIf you have one
Area Code
Phone Number
7
Pregnant Person's Cellphone
Area Code
Phone Number
8
Partner/Support Person's Name
First Name
Last Name
9
Partner/Support Person's text number
Area Code
Phone Number
10
Second Partner/Support Person's Name (if applicable)This would be anyone else that might be at the birth to support.
First Name
Last Name
11
Care Provider(OBGYN/Midwife)
First Name
Last Name
12
Planned Birthing Location * This field is required.Home/Birth Center/Hospital
Facility Name
13
Planned Birthing Location Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
What number pregnancy is this for you?
15
Number of previous births
16
Have you given birth before?* This field is required.
No
Yes, Vaginally only
Yes, Cesarean only
Yes,Vaginally and Cesarean
17
Number of living children
18
Any medical conditions developed during a previous pregnancy
None
Gestational Diabets
Group B Strep
Severe Insominia
Anxiety
Depression
Hyperemesis Gravidarum (severe morning sickness)
Anemia
heartburn
Headaches
Pica
Back Injury/Pain
Preeclampsia
Eclampsia
Other
19
About this pregnancy/baby
20
Please list any medical conditions before conception that would impact pregnancy or birth
21
Estimated Due Date* This field is required.
Month
Day
Year
22
Planned Method of Feeding
Breastfeeding
Formula Feeding
Both
Not sure but would like more information
23
About your health
24
Have any medical conditions developed during this pregnancy so far?
None
Gestational Diabets
Group B Strep
Severe Insominia
Anxiety
Depression
Hyperemesis Gravidarum (severe morning sickness)
Anemia
heartburn
Headaches
Pica
Back Injury/Pain
Preeclampsia
Eclampsia
Other
25
Preperation for Birth
26
Please list any other classes you have taken or plan on attending.Consider Handwaves- https://handwavesbirth.myshopify.com/products/online-childbirth-education-class
27
Who do you plan to have present with you at your labor?* This field is required.Check all that apply
Partner
Mother/ Mother-in-Law
Sister
Friend
Birth Photographer
Other
28
Topics you would like to discuss
Ways labor can begin
early signs of labor
stages of labor
timing and contractions
natural comfort strategies
pain management
breathing techniques
positions for labor
unmedicated/medicated labor/birth
unmedicated/medicated inductions
general triage procedures
common medical procedures in labor
positions for pushing
episiotomy
assisted vaginal delivery
cesarean delivery
post-birth procedures
newborn procedures
postpartum healing
postpartum support planning
feeding and breastfeeding
newborn care
postpartum mood disorders
postpartum nutrition
placenta encapsulation
placenta tincture
placenta salves/lotions
perineum care
postnatal expectatoins
csection recovery
VBAC Specific information
breastfeeding
breastpumps
infant massage
circumcision vs intact
car seat installation and use
baby wearing
Birth bag what to pack
pregnancy tinctures/herbs
postpartum tinctures/herbs
infant medical decisions
29
What are your expectations of me as your doula?* This field is required.
30
Any other questions or concerns?
Should be Empty: