New Client Intake Form
Basic Info:
Mother
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Occupation & Place of Work
Father
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Occupation & Place of Work
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Others Living in the Household & Ages
Do you have pets?
Yes
No
How did you hear about me?
*
Please Select
Website
Instagram
Facebook
Friend
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:
Drink more than 200mg of caffeine a day
Drink Alcohol
Smoke
Use other substances
Do you exercise?
Type & Frequency
History of anxiety, depression, trauma, or psychological issues?
About Your Pregnancy & Childbearing History
Was this a planned pregnancy?
Yes
No
How do you feel about this pregnancy?
Who is your birth provider (name of doctor or midwives)?
Estimated Due Date
-
Month
-
Day
Year
Date
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?
Yes
No
Are you planning on having music playing?
Yes
No
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?
Submit
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