New Client Consultation Form

Client Pregnancy Consultation Form

The following information will be used to help plan a safe and effective treatment. Please answer the questions to the best of your knowledge. All information will remain private & confidential.
Treatment Required

Antenatal classesAntenatal breastfeedingDad to be ClassBirthplan designBreastfeeding supportOther
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Parity (Number of births)
Gravity (number pregnancies)
Pregnancy Week*
Due Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

City

Country
Phone Number*

PrefixPhone Number
E-mail*
Occupation
How did you hear about me?*

Website / Online SearchInstagramFacebookReferralOther
If Referral, please list name
If Other, please let me know
What is the objective of your visit? *
Pregnancy Information:
Do you suffer from any of the following pregnancy related conditions?*

BackacheMorning SicknessHeartburnHeadaches / MigraineSinusesDepression / Anxiety / Panic AttacksDiarrhea / Constipation / IBSSciaticaAnemiaOedema (Swelling)High Blood PressureLow Blood PressurePalpationsVaricose VeinsHaemorrhoidsPelvic Girdle InstabilitySymphysis Pubis LaxityCapal Tunnel SyndromeVaginal BleedingAbdominal PainSensory Loss (numbness)Urination IssuesLeg Cramping / PainClotting issue (suspected deep vein thrombosis)Protein, sugar or blood in urineAny other conditions not listed here (please go into detail below)None
Please detail any other conditions:
Current Medication (incl vitamins):*
Tell me about your baby (delivery, age, sex, any concerns)
Your General Health
Stress Levels*

HighMediumLown/a
Exercise / Hobbies?
Have you experienced any of these health conditions in the past or present?*

Hormone Imbalance (eg PCOS / irregular cycle)CancerHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesCovid-19OtherNone
If you checked yes to any of these please provide further information. If not mark N/A*
Any known allergies (eg: aspirin, latex, nuts, essential oils)?*

YesNo
Are you a smoker? *

YesNoSocial
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo
Do you drink alcohol*

YesNo
What is your daily water intake (glasses / litres)*
Is there any other information you would like to make your midwife aware of? If yes, please give details:
I occasionally contact clients to follow up on a session and I also send booking confirmation and a reminder via email / SMS. I occasionally send emails regarding company news, updates, special offers etc. You may unsubscribe from these marketing emails at any time. Please confirm you give your permission for Your Midwife to:*

Contact you about appointment and relevant follow up.Send occasional emails with news, special offers etc.
Signature*

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Thank you for taking the time to complete this form - I look forward to seeing you soon.

Laura
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Client Pregnancy Consultation Form

Pregnancy Information:

Your General Health