New Client Intake Form

New Client Intake Form
Basic Info:
Mother

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Occupation & Place of Work
Father

First NameLast Name
His Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
His Email
example@example.com
His Occupation & Place of Work
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Others Living in the Household & Ages
Do you have pets?
What type of pets?
How did you hear about me?
Health History
How is Your Health?
Allergies
Ex: Drugs, Food, Tape, Latex
Special Diet
Routine Medications
Vitamins/Supplements
Do you have any medical conditions?
Do you currently:
Do you exercise?
Type & Frequency
History of anxiety, depression, trauma, or psychological issues?
About Your Pregnancy & Childbearing History
Was this a planned pregnancy?
How do you feel about this pregnancy?
Who is your birth provider (name of doctor or midwives)?
Estimated Due Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How was the due date determined?
Ex: last menstrual period, ultrasound measurements
Have you had any ultrasounds this pregnancy?
How many; where there any abnormal results?
Did you find out the gender of the baby?
If yes, please list gender
Mother's Blood Type
Father's Blood Type
Have you had any prenatal screening or special diagnostic testing?
Ex: blood tests, amniocentesis, tissue sampling, Rh titers
Do you have a preferred method of Natural Family Planning?
How many times have you been pregnant?

Prior Births of Your Children:

Rows	Name	Date of Birth	Sex	# Weeks	Length of Labor	Complications (include if C-section)
1
2
3
4
5

What has been your prior experience of breastfeeding?
Have you ever had postpartum depression or anxiety?
Plans For This Birth
What is your vision for this birth?
What are your expectations of your doula?
What is your plan for coping with the potential pain of labor?
Do you have a Birth Plan written out?
Are you planning on having music playing?
Are you planning on photos or video being taken?
Professional or amateur?
Do you have any spiritual preferences?
Mention types of prayer you prefer; leave blank if you don't mind different types of prayer; or please state "do not pray out loud with me" if that is your preference.
Additional people you would like present during labor?
Plan for care of children or pets during labor? (if applicable)
Do you have any special ideas about what you might like during labor?
Sight, sound, smell, touch, taste
Are there any positions, breathing, or relaxation techniques you have practiced or would like to use?
Is there anything else you would like me to know to best support you?
Should be Empty:

New Client Intake Form

Health History

About Your Pregnancy & Childbearing History

Plans For This Birth