Pregnancy intake Form
Street Address Line 2
State / Province
Postal / Zip Code
Your birthdate and age
Your Ob-Gyn/ Midwife name and number
When is the Due Date? How many weeks pregnant are you?
Have you had any complications or problems with this pregnancy?
Amniotic fluid leakage
High blood pressure
Rapid weight gain
Protein in urine
Abnormal fetal growth, heart beats or movements
High blood sugar
Do you have any medical conditions?
Connective Tissue/collagen disorder
Are you currently experiencing any infection or disorder?
Is your pregnancy considered high risk due to
Previous complicated pregnancy
Under 20 years old
Over 35 years old
Fetal genetic disorders
Exposures to hazardous materials
Is there relevant information about this pregnancy that I should know?
Where are you feeling pain or discomfort?
Which activities provide relief? Which activities aggravate it?
Which types of exercise are you doing during this pregnancy?
Are you allergic to any of the following?
Lavender essential oil
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