Intake Form Pregnant Mama's Name * First Name Last Name Pregnant Mama's Email * Pregnant Mama's Phone * (###) ### #### Pregnant Mama's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Partner/Support Person's Phone * Partner/Support Person's Email * Emergency Contact * Name/Relationship/Phone Number Estimated Due Date * MM DD YYYY Care Provider's First and Last Name * Type of Provider * Midwife OBGYN Family Physician Other (please specify) Other Provider specify here Clinic Name * Clinic Address * Clinic Phone Number * Location where you plan to deliver? * Home Stand-alone Birth Center Hospital Name and address of backup hospital if you plan to deliver at a birth center or home Do you have health insurance? * Yes No Health Insurance Name and Member Number * Do you have allergies? (if yes, please list) * Have you had any illnesses, surgeries, injuries. accidents or trauma recently or in past? (if yes, please describe) * Do you currently take any prescription or non-prescription medications (herbs, natural supplements, vitamins, overthe-counter)? If yes, please list what you take and what it’s for. * Do you currently have, or do you have a history of, any of the following medical conditions? (circle all that apply) * High blood pressure Low blood pressure Type 1 Diabetes Type 2 Diabetes Asthma Anemia Migraine headaches Menstrual problems Uterine Fibroids Scoliosis Seizure disorder/epilepsy Cancer HIV Herpes HPV/Genital warts Abnormal blood clotting Carpal tunnel syndrome None of the above Do you currently have, or do you have a history of any of the following psychological conditions? (circle all that apply) * Anxiety Depression Bipolar disorder Schizophrenia Post-Traumatic Stress Disorder Dissociative disorder Personality disorder Obsessive-Compulsive disorder Phobia(s) Anorexia Bulimia Binge Eating Addictive behavior Chronic insomnia None of the above Other medical/psychological condition not listed above * Do you currently see a therapist or counselor? * Yes No Explain anything else you would like me to know about your health * Previous Pregnancy Information How many times have you given birth? And were any twins, triplets, etc? * Out of previous pregnancies, how many were carried to term (37 weeks +)? * Out of previous pregnancies, how many were preterm (born 24 – 37 weeks)? * How many children do you have? Please list name(s) and age(s) * What type of births have you experienced? (check all that apply) * This will be my first birth Vaginal C-section VBAC (vaginal birth after cesarean) Elective induction Induction for medical reasons (please list what reason below) Home Birth Hospital Birth Birth Center Birth Water Birth List induction reason here (put NA if does not apply) * How long did your previous labor(s) last? (put NA if does not apply) * Have you had any of the following pregnancy-related health conditions in PAST pregnancies? (circle all that apply) * None Pre-Eclampsia Preterm labor Low birth weight Macrosomia (large baby) Polyhydramnios Oligohydramnios Group B Strep Gestational Diabetes Placenta Previa Placenta Abruption Vena Cava Compression Postpartum Hemorrhage Postpartum Depression Genetic Disorder RH Incompatibility Intrauterine Growth Restriction (IUGR) Hyperemesis Gravidarum (excessive vomitting) Gestational Hypertension (high blood pressure only during pregnancy) Other (please specify below) Other pregnancy-related health conditions Are you expecting multiples (twins, triplets, etc)? * Gender of the Baby (circle the applicable answer) * Boy Girl Don't know yet but will find out It will be a surprise! Other (list below) Other (ex: for twins, one of each or set of boys) * Do you have a name(s) picked out? If yes, you can share it with me here if you would like * Do you plan to share the name with others? * Yes No We would like it to be a surprised for some people so please don't share the name(s) Have you taken, or are you planning on taking, any childbirth education classes? If so, what classes and where will/did you attend them? * What type of birth are you hoping for? (circle the applicable answer) * Vaginal Cesarean birth VBAC Elective induction Induction for medical reasons Water birth Do you plan to birth (mark the applicable answer) * No pain medications/comfort measures only Epidural Other pain medications Unsure Other (please specify below) Specify here * Have you had any of the following pregnancy-related health conditions in your current pregnancy? (circle all that apply) * Rh incompatibility Hyperemesis Gravidarum (excessive vomiting) Gestational Hypertension (high blood pressure during pregnancy) Pre-Eclampsia Preterm labor signs Intrauterine Growth Restriction (IUGR) Low birth weight Macrosomia (large baby) Polyhydramnios Oligohydramnios Group B Strep Gestational Diabetes Placenta Previa Vena Cava Compression Genetic Disorder Other (please specify below) None Specify here * Do you have a birth plan/vision? * (If you have a birth plan/vision already, please email a copy to me) Yes No Need help What are the 3 most important outcomes that you desire for this birth? * Please describe the role you envision for me at your birth * Who else will be with you at the birth, and what role would you like them to play? * Is there anyone that you do NOT want to be present at the birth, or during the immediate postpartum period? * What would your partner like me to do to help them be more supportive to you during labor? * Do you have any religious or cultural beliefs that you would like me to be aware of? * Have you had any difficulties/complications/restrictions (physical, emotional, or other) with and during this pregnancy? * Do you have any fears about this birth? * What type of comfort measures do you think you would like to use during labor? * Distractions Breathing Patterns Massage Birth ball Walking, dancing, swaying Water (shower/tub) Hot/cold packs Visualization/Imagery Focal Points Aramatherapy Position changes Music Other (list below) Other comfort measures - list here * Are you planning on breast feeding your baby? * What have you been taught about birth (from your mother or others)? * Describe your dream birth * Have you taken a tour of your birthing place? * Yes No I plan to Please describe your physical and emotional prenatal and pregnancy experience so far: * Any specific topics you would like for us to discuss during prenatal meetings (i.e. early labor signs, stages of labor, timing contractions, natural comfort strategies, positions for labor, positions for pushing, common medical procedures, cesarean delivery, cesarean healing, postbirth procedures, newborn procedures, newborn care, postpartum healing, postpartum support & planning, postpartum mood disorders, postpartum nutrition, advocating for yourself) * Are you and/or your partner/support person reading and books on pregnancy/childbirth/postpartum or breastfeeding. Please list below. * Or would you like me to recommend some books? Do you have postpartum support plan or would you like to create one together? * Have you discussed protocols with your care provider if you go past your estimated due date? * How long until you and your care provider are comfortable with baby staying until an induction is necessary? * Please describe any activities you have been doing to physically/emotionally prepare for your birth. (ex. meditation, exercise, etc.) * Have you packed a birth bag? (If no, we can do this together if you would like)? * Yes, done No, but will get it done No, would like help to do this What do you think will be your greatest challenge for this pregnancy/birth/postpartum experience? * What do you think will be your greatest strength for your pregnancy/birth/postpartum experience? * If a hospital birth, please check your immediate postpartum preferences that differ from the routine process: * Waive eye ointment Waive Vitamin K shot Waive PKU test Waive Glucose test Waive Hepatitis B vaccine Don't know yet, would like to discuss or do more research Photographic Release * If you would like photography to document your pregnancy, labor and birth, postpartum, and the situation allows it, I am happy to take non-professional pictures, and with your consent, share them on my website and social media platforms. Please let me know your preferences below, or if you would like to discuss further. Yes I consent. You can use (non-explicit) of me, partner, baby with my approval from our meetings, classes, birth, and postpartum meetings. No thank you. I am flattered but woud like to keep the pictures private. Let's chat some more on this Yes, only from prenatal meetings, childbirth education, and postpartum meetings (not birth) Thank you!