Birth Client Intake Form
Congratulations on your pregnancy. Please take a moment to fill out the form below to the best of your ability before our first prenatal visit. If any of the questions don't apply, answer with N/A.
Mother's name *
Your answer
Partner's name(if applicable) *
Your answer
Estimated Due Date *
MM
/
DD
/
YYYY
Mother's Birthdate *
MM
/
DD
/
YYYY
Phone Number *
Your answer
Other Phone(if applicable)
Your answer
Email *
Your answer
Address *
Your answer
Baby's Gender *
Multiples
How did you hear about us? *
Your answer
Place of Delivery *
Hospital, Homebirth, Birthing Center( please specify which hospital or birthing center)
Your answer
Care Provider's Name, Address, Phone, and Name of Medical Group *
Your answer
How do you feel about your care provider?
supportive of your birth preferences, easy to communicate with, etc
Your answer
Back-up Hospital
If you are planning a homebirth
Your answer
Have you taken a tour or registered? *
Hospital Birth
Your answer
Would it be okay if I take pictures of your birth? *
I'm not a pro but I have a digital camera and would be happy to take some photos
Required
Health History
Please describe your health in general(pre-pregnancy) *
Your answer
To the best of your knowledge, do you have any of the following *
Required
Allergies
Your answer
Please list any other chronic illnesses
Your answer
Please list any medications you take regularly
Your answer
Have you ever had anesthesia? What kinds? Any complications?
Your answer
Childbearing history
If applicable, skip if none
Have you had any childbearing losses?
i.e.abortion, miscarriage, stillbirth, infertility, or children placed for adoption
Your answer
Please tell me about any previous birth(s)
i.e. date, gender, name, and birth weight
Your answer
What type of birth(s) did you have with your previous birth(s)?
Vaginal or Cesarean? How did labor start? How long was your labor? How did you push? What coping techniques did you use? Did you breastfeed or formula feed or both?
Your answer
Please list any complications associated with these birth(s)?
Complications with the birth itself, immediate health of you/baby, with breastfeeding, etc.
Your answer
What was the best thing about your previous birth experience(s)
Your answer
Which elements would you like to avoid this time?
Your answer
Upcoming Birth
Do you want a birth preference/plan?
I can help you with this
Have there been any issues with this pregnancy? If so, please list.
Your answer
Please list any childbirth classes that you have taken
If you haven't, do you plan to?
Your answer
Please check the box if you would like resources for birthing education classes.
Have you read any books on labor and childbirth, or postpartum? If so, which ones?
Please let me know if you would like recommendations
Your answer
Person(s) you would like in your birthing room *
Your answer
Is there anyone that you absolutely don't want in the birthing room? *
Your answer
Do you have any concerns or fears about your upcoming birth?
Your answer
Do you have any preferred comfort measures for pain or stress? How well do they work? *
i.e. warm bath, massage, distraction, music, rhythmic movement, etc.
Your answer
Are there any scents that you don't like?
Your answer
Baby
Do you have a nickname for the baby or do you have a name picked out already?
You do not have to share if you want it to be a surprise
Your answer
Do you have an ideal way of welcoming your baby? *
Immediate skin-to-skin, nursing, etc.
Your answer
Do you plan on breastfeeding or formula feeding? *
Your answer
If you are planning to breastfeed, have you taken any classes or read any books to prepare for breastfeeding?
If yes, would you like more resourses/support?
Your answer
Are you interested in cord blood banking? *
Are you interested in delayed cord clamping? *
Required
Are you planning to circumcise your baby?
Newborn procedures(please check all that apply) *
Required
Are you planning on cloth diapering?
Is there anything in particular you would like to discuss during our visit? *
Required
Is there anything else you would like to discuss or share with me?
i.e. Breastfeeding and going back to work, community support, religious background, postpartum help, etc.
Your answer
At what point during labor would you like me to join you? *
When it begins, at home, or at the hospital, active labor, etc?
Your answer
At what point during labor would you like to leave/arrive for your place of birth?
If homebirth, leave blank
Your answer
What is the best way to keep in touch? *
Required
Is there any additional information you would like to share?
Your answer
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