Client Intake Form
Please complete the following form, it should take between 5-10 minutes.
Personal Information
Full Name
*
First Name
Last Name
Preferred Name
DOB
-
Month
-
Day
Year
Date
Legal Sex
*
Female
Male
Other
Pronouns
Please Select
She/Her/Hers
He/Him/His
They/Them/Theirs
Other
Gender Identity
Woman
Man
Transgender
Nonbinary
Other
Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White
More than one ethnicity
Prefer not to say
Other
Preferred Language
Contact Information
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Relationship
What is your relationship status?
Single
Married
Divorced
Widowed
Partnered
Other
If applicable, partner's name
Emergency Contact
Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Relationship
Services & Programs
Services & Programs
Please indicate your interest in any of the additional services or programs listed below. We will follow up with more information tailored to your selections.
Additional services
Acupuncture
Herbal Medicine Prescriptions
Lifestyle Advice
Pelvic Floor Physical Therapy
Bodywork / Massage Therapy
Chiropractic Care
Reiki
Movement (yoga or dance)
Yoni Steam
Mental Health Support
Nutrition Consultation
Lactation Consultation
Community Building
TBP Perinatal Education
Comprehensive Childbirth Ed: 3 week series
Hospital Birthing & Advocacy
Comfort & Coping Strategies for Labor
Preparing for a Cesarean Birth
Labor Induction
The Epidural
In-house Programs
Womb Bus, Passerby/ Participant
CBC's Together, a BIPOC Doula Mentorship
Youth upLifting Optimal Health (YuLOH)
Partner or Community Programs
LSA
The Bronx Health Link
Doula via (Ashe, BxR, CBC, DES, other)
Nurse Family Partnership
Other
Gynecologic History
Gynecologic History
Have you had a period?
Yes
Never had a period
Are your periods regular?
Yes
No
Average length of period
If unsure, please write "Unsure"
Average cycle length (every X days)
If unsure, please write "Unsure"
Are there any problems with your periods?
Pain
Irregularity
Headaches
Nausea
Fainting
Heavy flow
Diarrhea
Migraines
Vomiting
Clots
Bleeding between periods
Migraines with aura
Dizziness
None
Other
Are you currently sexually active?
Yes
No
Never been
Other
What types of sexual activity do you engage in?
Vaginal intercourse
Oral sex
Anal intercourse
Non-penetrative sexual activities
Use of sex toys
Prefer not to say
Other
How many sexual partners do you have?
Current contraceptives and/or protection
None
IUD
Tubal ligation
Implant
Vasectomy
Condoms
Cycle tracking
Depo
Combined pill
Other
Last Pap
-
Month
-
Day
Year
Date
If you can not remember your last pap
Never had
Unsure
Other
Result of last pap
History and treatment for any abnormality
Last STI screening
-
Month
-
Day
Year
Date
If you can not remember your last STI screening
Never had
Unsure
Other
Any history of infectious diseases or STIs
None
Syphilis
HPV
Herpes
HIV/AIDs
Chlamydia
Hepatitis B
Gonorrhea
Trichomoniasis
Other
Last mammogram
-
Month
-
Day
Year
Date
If you can not remember your last mammogram
Never had
Unsure
Other
History and treatment for any abnormality with mammograms
Obstetric History
Pregnancy Information
Are you currently pregnant?
Yes
No
To help date your pregnancy, please chose one of the following dates
Please Select
First day of last menstrual period (LMP)
Estimated due date (EDD)
Date of conception (DOC)
Unsure of due date
If date selected, please enter it below
-
Month
-
Day
Year
Date
Have you had any ultrasound scans?
Yes
No
When was your last ultrasound scan?
Are you currently receiving care from a midwife or OB/GYN?
Yes
No
If yes, please provide their details below
Obstetric History
How many times have you been pregnant?
Pregnancy #1
Date of birth or end of pregnancy
-
Month
-
Day
Year
How many weeks in gestation?
What was the outcome of this pregnancy?
Spontaneous abortion (SAB)
Therapeutic abortion (TAB)
Normal spontaneous vaginal birth
Assisted vaginal birth (e.g. forceps)
Cesarean section
Other
If Cesarean is chosen, what was the urgency?
Elective
Emergency
If Cesarean is chosen, what was the scarring type?
Transverse
Vertical
T-shaped
Any procedure needed for SAB or TAB?
Medication
Dilation and curettage (D&C)
Aspiration
Other
Were there any complications with the pregnancy, delivery, or postpartum period?
Where was the location of the delivery?
Where was the location of the delivery?
Home
Birth center
Hospital
Other
Is this child currently living?
Yes
No
Child's name
First Name
Last Name
Child's sex
Please Select
Female
Male
Other
Child's sex
Female
Male
Other
If this pregnancy was for more than one child e.g. twins. Please provide additional information below
Pregnancy #2
Date of birth or end of pregnancy
-
Month
-
Day
Year
How many weeks in gestation?
What was the outcome of this pregnancy?
Spontaneous abortion (SAB)
Therapeutic abortion (TAB)
Assisted vaginal birth (e.g. forceps)
Assisted vaginal birth (e.g. forceps)
Cesarean section
Other
If Cesarean is chosen, what was the method?
Elective
Emergency
Transverse
Vertical
T-Shaped
Any procedure needed for SAB or TAB?
Medication
Dilation and curettage (D&C)
Aspiration
Other
Were there any complications?
Where was the location of the delivery?
Is this child currently living?
Yes
No
Child's name
First Name
Last Name
Child's sex
Please Select
Female
Male
Other
If this pregnancy was for more than one child e.g. twins. Please provide additional information below
Pregnancy #3
Date of birth or end of pregnancy
-
Month
-
Day
Year
How many weeks in gestation?
What was the outcome of this pregnancy?
Spontaneous abortion (SAB)
Therapeutic abortion (TAB)
Normal spontaneous vaginal birth
Assisted vaginal birth (e.g. forceps)
Cesarean section
Other
If Cesarean is chosen, what was the method?
Elective
Emergency
Transverse
Vertical
T-Shaped
Any procedure needed for SAB or TAB?
Medication
Dilation and curettage (D&C)
Aspiration
Other
Were there any complications?
Where was the location of the delivery?
Is this child currently living?
Yes
No
Child's name
First Name
Last Name
Child's sex
Please Select
Female
Male
Other
If this pregnancy was for more than one child e.g. twins. Please provide additional information below
Additional Pregnancies
Please enter details about the additional pregnancies
Your provider will be informed and will follow up.
Medical History
Medical History
Do you have any chronic medical conditions?
Yes
No
What condition(s) do you have?
Diabetes mellitus (Type 1)
Diabetes mellitus (Type 2)
Thyroid disorders
Polycystic ovary syndrome (PCOS)
Irritable bowel syndrome (IBS)
Celiac disease
Fibromyalgia
Osteoporosis
Endometriosis
Rheumatoid arthritis
Lupus
Multiple sclerosis
Chronic kidney disease
Migraines
Hypertension
Asthma
Do you have any current mental health problems or diagnoses?
Yes
No
What condition(s) do you have?
Depression
Post-traumatic stress disorder (PTSD)
Alcohol use disorder
Bipolar disorder
Acute stress disorder
Obsessive-compulsive disorder (OCD)
Generalized anxiety disorder (GAD)
Adjustment disorders
Body dysmorphic disorder
Social anxiety disorder
Insomnia
Chronic kidney disease
Specific phobias
Narcolepsy
Hoarding disorder
Anorexia nervosa
Bulimia nervosa
Binge-eating disorder
Schizophrenia
Schizoaffective disorder
Attention-deficit/hyperactivity disorder (ADHD)
Autism spectrum disorder (ASD)
Borderline personality disorder (BPD)
Antisocial personality disorder
Narcissistic personality disorder
Do you have any blood borne illnesses?
Yes
No
If yes, which illness?
HIV
Hepatitis
Other
Have you had any previous abdominal surgeries?
Yes
No
Are you currently taking any prescribed or OTC medications or supplements?
Yes
No
Do you have any allergies?
Yes
No
Do you have any medical problems in your family?
Yes
No
If yes, please select which
Heart conditions
Cancer
Diabetes
Mental health
Stroke
Hypertension
Bleeding disorders
Other
Existing Coverage
Insurance
Insurance provider
Insurance number
e.g., Member ID, Medical Record Number
Primary Physician
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Lifestyle
Lifestyle
Do you smoke cigarettes or use tobacco products?
Yes
No
Quit 1+ year ago
Quit less than a year ago
Other
Do you drink alcohol?
Yes
No
If yes, how much alchohol per week?
Do you use recreational drugs?
Yes
No
Do you consider yourself to have a healthy balanced diet?
Yes
Somewhat
Mostly
No
Do you engage in regular physical exercise?
Yes
No
Light exercise (e.g., walking, yoga)
Moderate exercise (e.g., brisk walking, swimming)
Vigorous exercise (e.g., running, cycling, high-intensity)
Other
Do you have any dietary requirements?
Gluten intolerance
Lactose intolerance
Vegetarian
Vegan
Pescatarian
Other
Social Information
Do you have social support available?
Yes I feel supported
Sometimes
No
Other
Do you feel safe?
Yes I feel safe
Somewhat
No
Other
Do you feel safe in your current relationship?
Yes
Somewhat
No
Other
Does your partner ever try to control what you do, who you see or talk to, or where you go?
Yes
Somewhat
No
Other
Do you have any concerns about the safety of your children?
Yes
Somewhat
No
Other
Has your partner ever forced you into sexual activities that you did not want?
Yes
Somewhat
No
Other
Has your current partner ever threatened you or made you feel afraid?
Yes
Somewhat
No
Other
Have you previously experienced violence, aggression or controlling behavior from a partner? Please provide details
Yes
No
If yes, please explain
Are you currently employed
Full time
Part time
Full-time student
Part-time student
Unemployed
Other
Do you feel financially secure?
Yes
Somewhat
No
Other
Do you have adequate transportation to get to medical appointments?
Yes
Sometimes
No
Other
What is your housing situation today?
I have housing
I have housing but I am worried about losing it in future
I do not have housing
I am staying with friends/family
Other
Do you have access to enough healthy food?
Yes
No
Other
If no, please explain
Are you part of any local or national level programs? Examples: WIC, Healthy Start (please state)
Additional Information
Additional Information
Anything else you would like us to know about your medical history?
Submission
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