Client Intake Form

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Client Intake Form

Complete to the best of your ability. All information entered is confidential regardless of service retainment status.

Visit hiermanna.com or reach Andrea at (305) 988-0365 and hiermannadoula@gmail.com with any questions.

Email *

Record my email address with my response

Name *

Date of Birth *

Birth Partner(s) *

Occupation *

Phone number *

Email address *

Address *

Non-medical labor attendees *

Additional family members offering postpartum support *

Insurance provider *

How did you hear about Hiermanna? *

Is this your first birth? *

Baby's sex

Baby's name

Due Date *

Primary care provider *

Phone number *

Birth facility *

Have you toured this facility? *

Yes

I have a tour scheduled.

Have you taken any Childbirth Education classes? *

Yes

I'm scheduled to take one before my baby's birth.

Pediatrician *

Pediatric facility

Phone number

How would you describe your health? *

Any particular health concerns? *

Any allergies? *

Medications *

Vitamins/supplements/OTC's *

General dietary habits and restrictions *

Level of physical activity *

Sedentary

Lightly Active

Moderately Active

Very Active

Major surgeries/hospitalizations *

Emotional/sexual trauma *

Yes

Why is this necessary?

Alcohol/smoking/drug use *

Frequent

Some

None

Did you experience PMS or cramping before your pregnancy? *

Frequently

Sometimes

Not at all

If you did, what coping techniques did you use? *

Was your pregnancy planned? *

Any previous pregnancies and birth experiences? *

Any particular concerns about labor or the postpartum period?

Any experience breastfeeding?

Any history of postpartum depression? *

If yes, please describe any treatment or counseling: *

Please select or list any pregnancy symptoms or conditions you may have: *

Acid indigestion

Anxiety

Carpel tunnel syndrome

Bowel problems

Fatigue

Hemorrhoids

Incontinence

Lack of sleep

Muscle cramps

Nausea and vomiting

Shortness of breath

Swelling

Gestational diabetes

STD's

Group B strep

Other:

Required

Atypical ultrasound results? *

What is your vision for this birth? *

What are your expectations of your doula? *

Do you have a current plan for coping with the pain of labor? *

How do you feel about medical interventions in birth? *

Would you like photos or videos of your baby's birth? *

Any cultural or religious practices and traditions you'd like incorporated into your birth? *

What elements are most important to you during your labor experience? *

Feeling in control

Feeling clear-headed and alert

Avoiding induction

Avoiding medication

Minimal Pain

Being active and mobile

Bonding immediately

Seeing or touching my baby's head as it crowns

Other:

Required

Is there anything else I should know?

Do you plan to breastfeed or use formula? *

Breastfeeding

Formula

We'll see

Required

Do you intend to return to work? If so, how long after birth? *

Will your partner be at home with you after the baby is born? If so, for how long? *

What do you foresee as your family’s most important needs regarding postpartum care (laundry, errands, meal prep)? *

Do you have any other planned family, visitors, or hired help that will be present during the postpartum period? *

Is there anything else I should know to support you during your postpartum period? *

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