• Lily & Lavender Birth Limited

    Intake Form

    Lily & Lavender Birth
  • Today's Date
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  • Make sure you have confirmed your first appointment with Lily & Lavender Birth before filling out this form.

    With the assurance of confidentiality, the following information is taken in order to provide you with the most holistic care possible.  While any information given is appreciated and lends to the quality of care provided, it is always your right to skip a question. Please allow approximately an hour to fill out this form.  Thank you.  

    You will need: Basic information for your partner and/or the biological father, basic family medical history for you and the biological father, your vaccines card, and your past medical history.

  • Have you confirmed your first appointment with Lily & Lavender Birth?*

  • Please contact Lily & Lavender Birth to confirm your first appointment before filling out this form

    027 381 0770 - Call or Text to get started.

  • Māmā Details

    This form is a part of an assessment tailored for routine early pregnancy assessment.

  • Consent Statement

    This form is part of an assessment to support whānau (families) to thrive. It guides us through a best care assessment.  If you give your permission, information that does not identify you will be combined with many other people's information to report on and improve care for all hapū māmā (pregnant people), and pēpi (babies).

  • Consent*
  • Date of Birth*
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  • What ethnicity groups do you belong to?*
  • Do you have a GP?*

  • Whānau (family) Information

  • Do you have a partner?*
  • Is your partner the biological father?*
  • Living Situation*

  • Emergency Contact

  • Do you have a disability?*

  • Pregnancy Information

  • First Day of your Last Menstrual Period (LMP)*
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  • Estimated Due Date
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  • Calculation Method*
  • Estimated Due Date (from scan)
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  • What is the ethnicity of your baby (consider both biological parents)?*

  • Can you share with me your previous experiences of being hapū (pregnant) because it will help me to understand what your needs are now?

  • Have you had a miscarriage before?*
  • Have you had a termination before?*
  • Have you had a stillbirth before?*

  • Gynaecological History

  • Do you ever bleed/spot between periods?*
  • Are you able to differentiate vaginal fluids that are normal from that of an infection? (Quality, quantity, colour, sensations)*
  • Please check if you've ever had any of the following:
  • Cervical smear and HPV Screening Status*
  • Previous surgery on cervix?*

  • We ask every pregnant person about their sexual health.

  • Are there any current symptoms suggestive of an STI (sexually transmitted infection)?*
  • Types of sexual relationships (Male/Female/Both/Other)*
  • Are there any sexual partners for whom you don't/didn't know their STI status or who have a known STI?*
  • Did/Do you have unprotected sex (oral/vaginal/anal) with any of these partners with unknown status?*
  • Are there any sexual partners for whom you don't/didn't know their STI status or who have a known STI?*
  • Would you like more information and/or options regarding birth control?*

  • Medical

    Taha tinana (physical wellbeing)

  • Now that you are hapū (pregnant), it is important to consider any other problems you have now or in the past

  • Check "Yes" if you feel as though you experienced abuse, violence or malpractice from a care provider:*
  • Do you have any past or ongoing health problems?
  • Would you like more information and/or options regarding birth control?*
  • Are you and the baby's father related by blood?*

  • Genetic/Family History:

  • Please check if you, the baby’s father, or anyone in your families have had any of the following conditions.  (Siblings, grandparents, aunts, cousins of your blood line.)

  • Taha hinengaro

    Mental and emotional wellbeing

  • Pregnancy is a time of change, so we always ask about mental health and emotional well-being.

  • Have you ever experienced mental health problems?*

  • Over the last two weeks, have you been bothered by:

  • Little interest or pleasure in doing things?*
  • Feeling down, depressed or hopeless?*
  • Feeling nervous, anxious, or on edge?*
  • Not being able to stop or control worrying?*

  • Being hapū (pregnant) is a special time for well-being as you grow pēpi (baby). We ask the next questions for every hapū māmā to ensure they have the opportunity and choice to get extra support if they need it.

  • Do you have a stable, safe home with enough room for everyone?*
  • Is your home warm and dry?*
  • Do you feel you have the social and financial support you need now that you are hapū (pregnant)?*

  • Because family violence affects a lot of women and children, we ask about it in pregnancy.

  • Is there anyone in your life whom you are afraid of, who hurts you in any way or prevents you from doing what you want to do?*
  • Is there anyone at home who makes you feel you are no good or worthless?*
  • Have you ever had a relationship with someone who made you feel afraid, hurt you, or made you do things you didn't want to?*
  • Are you afraid of your partner or ex-partner?*
  • Have you been hit, kicked, punched, or hurt by someone in the last year?*

  • Final Questions:

  • How did you hear about us?

  • Acknowledgment and Waiver

    Scroll to the end before ticking the checkbox
  • Date Submitted
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