Restore Vitality Pregnancy intake Form

PREGNANCY Client Intake Form

Pregnancy can be demanding both physically & mentally. For most, a pregnancy filled with vitality doesn’t just happen by chance, it requires intentional nourishment. But where do we even start? That’s what I am here to offer : not just information & guidance, but that plus, support individualized to you!
You were meant for this!
Society has normalized pregnancy being a state of illness - that feeling miserable is the outcome of creating life. Symptoms that are normalized are often our bodies way of sending a message that theres an imbalance, deficiency or lifestyle shift needed.

Pregnancy is often treated as a ticking time bomb for a complication - becoming far too medicalized - instead of a entirely natural process that our bodies were made to perform well when given the right environment, building blocks, nutrition & support.

Women are cheated with impersonal quick prenatal visits, little emotional support, little to no preventive care, education about what's truly happening within our bodies, the mineral demands of motherhood, guidance in optimizing pregnancy, birth & postpartum, or education on proper nutrition during pregnancy.

We've lost autonomy. And interventions that could have been avoided leave women feeling that pregnancy and birth stole something from them.

As someone with two truly blissful pregnancies, birth & postpartum, I want the same for you and I truly believe its possible! When starting Restore Vitality I knew that with my passion for preconception preparation, optimizing pregnancy & birth, I had to open special coaching just for pregnant mothers!

I am here to help you not only survive pregnancy but thrive in it!
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Social media handle:*
If you don't have one, enter none.
E-mail*
example@example.com
Phone Number*
Format: (000) 000-0000.
EmailTextCallSocial media messaging
Occupation
Health History & Evaluation :

the more detailed you share, the better I will be able to support you on your pregnancy journey.
How would you rate your pregnancy so far?
When was your last menstrual cycle:*

MonthDayYear
Date
What is your estimated due date:*

MonthDayYear
Date
Height:*
Pre-pregnancy weight:*
Current weight:*
SingleIn a relationshipMarriedDivorcedComplicated
Not reallySomewhatYes, very much
YesNo
If no, please share how many and their ages:
YesNo
YesNo
YesNo
Clomiphene citrate (clmoid)Letrozole (Femara)GonadotropinsMetforminProlactin or Thyroid medicationsIUIDonor sperm inseminationIn vitro fertilization (IVF)Intracytoplasmic sperm injection (ICSI)Preimplantation genetic testing (PGT)Donor eggDonor embryoOther
Tubal surgeryUterine surgeryEndometriosis surgeryEgg freezingStem cell or regenerative therapyAcupuncture or integrative medicineChiropractic careNone of the above
YesNoNot that I’m aware of
Please give me an idea of the fathers vitality:*
Health conditions, occupation, overweight, sedentary, etc.
YesNO
30-32 daysEvery few monthsLess than 25 days40-45
Yes, slightlyYes, very muchYes, excruciatingNot reallyNo
YesNo
BBTLuteinizing hormone (LH)Follicle-stimulating hormone (FSHCervical mucusCervical positionEstrogenProgesteroneNot applicable
Vaginal birthCesareanVaginal birth after cesarean (VBAC)StillbirthEctopic pregnancyMolar pregnancyNone of the above
NoYes, miscarriageYes, other complication
YesNoNot applicable
YesNoNot sure yet
Yes, since becoming pregnantYes, before pregnancyNo neverNever been tested
YesNo
YesNoBefore pregnancy
Nausea with vomitingNausea without vomitingFatigueShortness of breathHeart palpitationsCrampingBreast changesBleeding or spottingDiscomfort with urinationNone of the aboveOther
If ‘other’ please elaborate:
GBSGestational diabetesHypermesis gravidarum (HG)Pre-eclampsiaSevere morning sicknessPlacenta previaPlacenta abruptionRetained placentaPlacenta accrete/percreta/incretaUTIPreterm laborLow blood pressureHigh blood pressureAnemiaSevere headachessubchorionic hematomaMTHFRPrenatal or postnatal depression or anxietyIntrauterine growth restriction (IUGR)MacrosomiaCongenital abnormalitiesOligohydramniosPolyhydramniosPremature rupture of membranes (PROM)ChorioamnionitisHELLP syndromeGestational hypertensionThyroid disorderUterine ruptureFetal distressPostpartum hemorrhageTwin pregnancySeptate uterusBicornuate uterusDidelphys uterusArcuate uterusUnicornuate uterusPreviously experienced amenorrheaT-shaped uterusIVFAbortionSTIHPVFibroidsPCOSEndometriosisInsulin resistanceAsthmaAllergiesGenetic disorderInsominiaAcid refluxMuscle achesAntibioticsRapid weight gainDizzinessDiabetesOther
If ‘other’ please elaborate:
YesNo
If yes, please list the medications, dosage, frequency and reason:
YesNo
If yes, which prenatal?
Example: Seeking Health Prenatal essentials
NoYes
If yes, please list:
YesNo
What inspired you to seek pregnancy coaching?*
What are you most worried about with pregnancy?*
What are you most excited about?*
YesNot reallySometimes
What are the 3 most important things you want us to focus on?*
YesNo
If yes, OB, CNM, CM, CPM, DEM, lay midwife, or other?*
YesNo
Not yetHomebirthHospital birthBirth centerEpiduralNatural/unmedicatedFreebirth
YesNot sure yetNo
YesNoSometimes
YesNoIn the past
Yes, bothYes, smellYes, foodNo
Are there any foods you avoid for health or religious reasons?*
Do you have cravings? If yes, please elaborate:
Food allergies or intolerances:
What is your grocery budget each month?*
Describe a typical day of eating:*
How would you rank your stress level?*

1

2

3

4

5

6

7

8

9

10

1 is Very low, 10 is Very high
<55-78-1012-14
NoYes
NoYes
If yes, please list with date blood was drawn:
Please describe a typical day:*
NoYes
YesNo
Blunt, directive & straight forwardGentle supportEducationalOther
Is there anything else you’d like me to know to better support you?
Restore Vitality Pregnancy Policy:

A thriving pregnancy - optimizing both mom and babies health - is one of my biggest passions. We underestimate the powerful difference properly nourishing and supporting our bodies will make in not only pregnancy outcome, but the health of mother and child for a lifetime after.

Pregnancy is not one-size-fits- all. And as your coach, I am here to help you find what your body needs to thrive, to help guide you to the resources that fit your needs, and support you in taking back your autonomy. I want to equip you with all the information you need to feel confident in nourishing yourself and caring for the incredible ability to create a precious life.

Coaching relies on open honesty, and mutual respect. I do not guarantee any prevention, healing or results, but rather offer evidence based information, resources, guidance and support.

I work with clients via email, text, phone and zoom. My life is primarily filled with mothering and farming, so I mostly work after hours. I aim to respond within 24 hrs, but in some cases it may take up to 48 hrs.

Not Medial Advice:

Restore Vitality is not a replacement for prenatal care from a licensed provider. I, Tiana, am not a licensed practitioner therefore I do not give diagnoses, treatments, prescribe medications or guarantee any outcome. The information provided is for educational purposes only and it is not intended as medical advice.

Client Agreement:
- I, the client, understands that Tiana, the coach, can not diagnose, treat, or cure any conditions or diseases. She can not prescribe medications or treatments.
- I am fully responsible for my physical, emotional, and mental well-being during and after coaching support.
- I understand that results are not guaranteed and Tiana is not responsible for any outcomes.
- I will be open and communicative. If a session is scheduled, I will arrive on time, if cancellation is necessary, 24 hr notice is required. However, form of appointment can be changed, such as from a zoom call to live messaging.
- All client information and services are confidential. Everything shared between client and coach remains private. Written consent must be given for any information to be shared, except in the incident of client being at risk of self harm or the harm of others. Disclosure is required by law.
- In the case of an emergency, client will contact local healthcare providers first.
- Payment must be made prior to a full coaching session.
- No refunds.
- I understand that either party may terminate coaching agreement with a written notice at any time.
- I understand that Restore Vitality coaching does not take the place of seeking the guidance and care from a medical professional.
By signing below, you acknowledge that you have read, agree to and understand the terms and conditions outlined. And you voluntarily enter this coaching relationship.
Date

MonthDayYear
Date
Signature

Powered by Jotform SignClear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

My Products

Restore Vitality Pregnancy Consultation

This includes a review summary of your intake form either via phone or email (your choice), aswell as simple suggestions to support you in the stage of pregnancy you’re currently in. For the full coaching you would need to purchase the month package. If you’d like to do a consultation before commitment, price is reduced from the full package.

$25.00 Quantity

Restore Vitality Pregnancy Security Deposit

While you can submit a form without payment, we will not be able to proceed forward without some commitment.

$50.00 Quantity

Restore Vitality Pregnancy Weekly Coaching Pay in Full

Price is for 1 month. You have access to all I have to offer you.

$350.00 Quantity

Glow & Grow Pregnancy Tea

Rich in vital vitamin & minerals, anti-histamine, supports energy, calming to the nervous system, promotes skin & hair health, supports liver detoxification & digestion, blood sugar balance, supports blood volume expansion, may reduce risk of hemorrhage, hydrating and overall uterine supportive. INGREDIENTS: organic raspberry leaf, organic nettle, organic alfalfa, organic oat straw, organic nettle, organic dandelion root, organic spearmint, sea salt. ** 15 servings.

$8.00 Quantity

Womb Ease Postpartum Bath

Astringent & styptic which helps reduce bleeding and promotes clotting, tones the uterus, soothing, healing to perineal tissue, reduces swelling, supports uterine involution, calming, anti-microbial, anti-inflammatory, mild antiseptics, promotes circulation, eases hemorrhoids, pain relieving. INGREDIENTS: ancient minerals magnesium flakes, organic shepherds purse, organic lavender, organic calendula, organic mugwort, organic yarrow, organic plantain leaf, sea salt.

$10.00 Quantity

Rest & Restore Postpartum Tea

Tones the uterus, rich in iron, calming, liver, kidney and lymphatic supportive, and packed with minerals that support rest, recovery, calm energy & restoration. INGREDIENTS: organic raspberry leaf, organic nettle, organic oatstraw, organic lavender, organic dandelion, organic alfalfa, organic calendula, sea salt. **15 servings.

$8.00

Enter coupon

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

PREGNANCY Client Intake Form

You were meant for this!

Health History & Evaluation :