Client Intake Questionnaire
Thank you for taking the time to fill out this form so that I can get to know you better and have an idea of how I can best support you during your pregnancy, birth, and postpartum journey.
Your Name
*
First Name
Last Name
Your Pronouns
Your Phone Number
*
-
Area Code
Phone Number
Your Birth Partner's Name
First Name
Last Name
Your Birth Partner’s Pronouns
Your Birth Partner's Phone Number
-
Area Code
Phone Number
Your Home Address
*
Street
House Number
City
State / Province
Postal / Zip Code
Your Email
*
example@example.com
Your Birth Partner's Email
example@example.com
Current Pregnancy Information
Estimated Due Date
*
-
Day
-
Month
Year
Date
Doctor/ Midwife's / Practice name
*
Delivery Location
Home
Birth Canter
Hospital
I'm not sure yet.
Address of delivery location if known:
Planned Method Of Feeding
Breastfeeding
Formula Feeding
Combination
Not sure but I would like more information
Are you currently experiencing any specific health or other concerns that affect this pregnancy? As with all of your information, anything you share will be kept confidential.
*
Explain any complications you have had with this pregnancy or any restrictions your caregiver has given you.
*
Pregnancy History
Have you given birth before?
*
No
Yes, Vaginally only
Yes, Cesarean Only
Yes, Vaginally and Cesarean
How would you describe your previous birth experiences?
Do you have a history of miscarriage or infant loss?
Yes
No
Birth Preparation
Have you taken or are you planning on taking any childbirth education classes?
*
Please list any other classes you have taken or plan on attending.
Who do you plan to have assist you with your labor?
*
Partner/Spouse
Doula
Mother/Mother-In-Law
Sister
Friend
Midwife
Other
Have you written a birth plan?
*
Yes, it is a final copy.
Yes, but it is a draft and I would like some help.
No, I would like like help writing one.
No, I have no interest in one.
In 5 words, please describe how you would like to FEEL and how you would like your birthing space to feel? (ex: calm, peaceful, energized, happy)
Are there any cultural/religious choices/preferences for your birth that I should know about?
Have you talked about your birth preferences with your caregiver?
How do you feel about interventions in labor/delivery?
What type of pain management would you like to use?
*
Comfort Measures
IV Medication
Epidural
I'm not sure, I would like more information.
Other
What type of comfort measures would you like to use in labor?
*
Distractions
Breathing Patterns
Massage
Birth Ball
Walking, Dancing, Swaying
Water (Tub/Shower)
Hot/Cold Therapy
Visualizations/Imagery
Focal Points
Aromatherapy (Essential Oils)
Music
Other
Please list any questions you have or topics you would like to discuss:
Submit
Should be Empty: