Birth Client Intake FormThis questionnaire will help me prepare for our first prenatal appointment.Please answer as thoroughly as possible and reach out with any questions. About You Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Age * Occupation * Support Team This questionnaire will help me prepare for our first prenatal appointment. Please answer as thoroughly as possible and reach out with any questions. * Do not include providers. Put asterisk (*) next to partner if applicable. Provider’s Name * Provider’s Phone Number * (###) ### #### Where will you be giving birth * How have conversations with your provider been going? * What classes have you taken/are you planning to take? * History These questions are optional and confidential. If you have been pregnant before, please share any information about your pregnancy, birth, and postpartum period that you would like me to know Do you have any medical conditions you feel may affect your pregnancy, birth or postpartum period? What do you know about your own birth? Is there anything else you’d like to share? Pregnancy and Birth These questions are optional and confidential. Describe your ideal vision for your birth. Include things such as words, imagery, mood, sounds, smells etc... How do you want to feel during and after the birth? What makes you feel better when you’re sick or not feeling well? What are your thoughts about pain management during labor? What do you imagine would be really helpful during the birth coming from your doula and other support team members? Have you had any prenatal testing? If yes, which tests? Are there any referrals you’d like from me at this time? Postpartum/Transition to Parenthood Do you feel like you have community support in the immediate area? Are you planning to breastfeed? If yes, are you taking a breastfeeding class? Is there anything else you would like me to know? Thank you!
