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.
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Mother's name *
Partner's name(if applicable) *
Estimated Due Date *
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Mother's Birthdate *
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Phone Number *
Other Phone(if applicable)
Email *
Address *
Baby's Gender *
Multiples
Clear selection
How did you hear about us? *
Place of Delivery *
Hospital, Homebirth, Birthing Center( please specify which hospital or birthing center)
Care Provider's Name, Address, Phone, and Name of Medical Group *
How do you feel about your care provider?
supportive of your birth preferences, easy to communicate with, etc
Back-up Hospital
If you are planning a homebirth
Have you taken a tour or registered? *
Hospital Birth
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) *
To the best of your knowledge, do you have any of the following *
Required
Allergies
Please list any other chronic illnesses
Please list any medications you take regularly
Have you ever had anesthesia? What kinds? Any complications?
Childbearing history
If applicable, skip if none
Have you had any childbearing losses?
i.e.abortion, miscarriage, stillbirth, infertility, or children placed for adoption
Please tell me about any previous birth(s)
i.e. date, gender, name, and birth weight
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?
Please list any complications associated with these birth(s)?
Complications with the birth itself, immediate health of you/baby, with breastfeeding, etc.
What was the best thing about your previous birth experience(s)
Which elements would you like to avoid this time?
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.
Please list any childbirth classes that you have taken
If you haven't, do you plan to?
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
Person(s) you would like in your birthing room *
Is there anyone that you absolutely don't want in the birthing room? *
Do you have any concerns or fears about your upcoming birth?
 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.
Are there any scents that you don't like?
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
Do you have an ideal way of welcoming your baby? *
Immediate skin-to-skin, nursing, etc.
Do you plan on breastfeeding or formula feeding? *
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?
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.
At what point during labor would you like me to join you? *
When it begins, at home, or at the hospital, active labor, etc?
At what point during labor would you like to leave/arrive for your place of birth?
If homebirth, leave blank
What is the best way to keep in touch? *
Required
Is there any additional information you would like to share?
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