Intake Form

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.

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).

Yes, I permit the sharing of my non-identifiable informationNo, I do not permit the sharing of my information. (You can continue this form and your info will not be shared).

First NameMiddle NameSurnamePrevious Surname

This will auto-fill once DOB is entered

Street Address

Street Address Line 2

City

Postal / Zip Code

YesNoWould like help getting one

DD-MM-YYYY (Best guess if you're not sure)

DD-MM-YYYY (Auto calculates once you enter the LMP)

Auto calculates once you enter the LMP

Calculated from LMPScanUnsure

Auto - calculates based on LMP

DD-MM-YYYY

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

Including those that ended in termination/miscarriage

Including Live/Stillborn

Completed within the last 3 yearsNot yet required (< 25 years)Overdue (previously screened)Never had a screen (>25 years)Undergoing treatment or follow-up for abnormal resultUnsure

We ask every pregnant person about their sexual health.

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

Type N/A if no known allergies

Comments regarding your/family conditions

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

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

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.

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

Intake Form

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

Māmā Details

Whānau (family) Information

Emergency Contact

Pregnancy Information

Gynaecological History

Medical

Genetic/Family History:

Taha hinengaro

Final Questions:

Acknowledgment and Waiver