Pregnancy intake Form
Fertile Hands
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
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?
Bleeding
Cramping
Amniotic fluid leakage
Swelling
High blood pressure
Rapid weight gain
Protein in urine
Vision disturbances
Severe nausea
Vomiting
Headaches
Abnormal fetal growth, heart beats or movements
High blood sugar
Do you have any medical conditions?
Diabetes
Heart
Liver
Kidney
Lung
Convulsive disorders
Uterine abnormallity
Connective Tissue/collagen disorder
Are you currently experiencing any infection or disorder?
Cold
Bladder infection
Breast infection
Skin irritation
Yeast infection
Varicose veins
Is your pregnancy considered high risk due to
Diabetes
Hypertension
Multiple pregnancy
Previous complicated pregnancy
Asthma
Rh factor
Genetic problems
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?
Olive oil
Jojoba oil
Coconut oil
Castor oil
Lavender essential oil
Submit
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