Intake Form Please enable JavaScript in your browser to complete this form.1GENERAL INFORMATION2EMERGENCY CONTACT3HEALTH CARE PROVIDER INFORMATION4GENERAL HEALTH INFORMATION5PREVIOUS PREGNANCY INFORMATION6CURRENT PREGNANCY INFORMATION7BIRTH WISHESNamePartner’s NameHome AddressE-mailPhone NumberPartner/Other Phone NumberAgeNextEmergency Contact NamePhone NumberRelationshipNextNameType of Provider:MidwifeDoctorOther (please specify)Specify HereAddressPhone NumberLocation where you plan to deliver?:HomeHospitalBirth Center OtherName and address of delivery location/backup hospital if you plan to deliver at a birth center or at homeDo you have health insurance?NextDo you have allergies? (if yes, please list)Have you had any recent illnesses, surgeries, injuries. accidents or trauma ? (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 forDo you currently have, or do you have a history of, any of the following medical conditions? (circle all that apply)High blood pressureLow blood pressureType 1 DiabetesType 2 DiabetesAsthmaAnemiaMigraine headachesMenstrual problemsUterine fibroidsScoliosisSeizure disorder / epilepsyCancerHIVHerpesHPV / Genital wartsAbnormal blood clottingCarpal tunnel syndromeNone of the aboveDo you currently have, or do you have a history of any of the following psychological conditions? (circle all thatAnxietyDepressionBipolar disorderSchizophreniaPost-Traumatic StressDisorderDissociative disorderPersonality disorderObsessive-CompulsiveDisorderPhobia(s)AnorexiaBulimiaBinge EatingAddictive behaviorChronic insomniaNone of the aboveOther medical/psychological condition not listed aboveDo you currently see a therapist or a counselor?Explain anything else you would like me to know about your healthconditionNextHow many times have you given birth? (twins, triplets, etc count as 1 birth)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)Have you given birth to multiples (twins, triplets, etc)?Which types of births have you experienced? (circle all that apply)This will be my first birthVaginalC-sectionVBAC (vaginal birth after Cesarean)Elective inductionInduction for medical reasonsHome birthHospital birthBirth center birthWater birthHow long did your previous labor(s) last?Have you had any of the following pregnancy-related health conditions in PAST pregnancies? (circle all that apply)Rh incompatibilityPre-EclampsiaPreterm LaborLow Birth WeightMacrosomia (large baby)PolyhydramniosOligohydramniosGroup B StrepGestational DiabetesPlacenta PreviaPlacental AbruptionVena Cava CompressionPostpartum HemorrhageGenetic DisorderIntrauterine Growth Restriction (IUGR)Hyperemesis Gravidarum (excessive vomiting)Gestational Hypertension (high blood pressure during pregnancy)None of the abovePlease tell me anything you would like me to know about your past pregnanciesNextBaby’s Due DateAre you expecting multiples (twins, triplets, etc)?Gender of the Baby (circle the applicable answer)GirlBoyOne of Each(twins)Don’t know yet but plan to find out It will be a surpriseDo you have a name picked out? If yes, you can share it with me here if you likeDo you plan to share the name with others?YesNoWe would like it to be a surprise for some people so please don’t share!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?vaginalcesarean birthVBACelective inductioninduction for medical reasonswaterDo you plan to birthNaturally (comfort measures/no pain medication)?Epidural?Other pain medication?Have you had any of the following pregnancy-related health conditions in your current pregnancy?Rh incompatibilityHyperemesis Gravidarum (excessive vomiting)Gestational Hypertension (high blood pressure during pregnancy)Pre-EclampsiaPreterm LaborIntrauterine Growth Restriction (IUGR)Low Birth WeightMacrosomia (large baby)PolyhydramniosOligohydramniosGroup B StrepGestational DiabetesPlacenta PreviaVena Cava CompressionGenetic DisorderNone of the abovePlease list any conditions you have that are not listed aboveNextDo you have a birth plan/vision?YesNoNeed helpIf you have a birth plan/vision already, feel free to attach a copy to this form.) Click or drag a file to this area to upload. What are the 3 most important outcomes that you desire for this birth?Please describe the role you envision for me at your birthWho 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?Have you had any difficulties/complications/restrictions (physical, emotional, or other) with and during this pregnancy? (copy)What type of comfort measures do you think you would like to use during labor?DistractionsWalking, Dancing, SwayingFocal PointsBreathing PatternsWater (tub/Shower)AromatherapyMassageHot/Cold TherapyMusicBirth BallVisualization/ImageryOther techniques you would like to useAre you planning on breast feeding your baby?Are there any particular topics that you would like to focus on during our prenatal visit(s)/conversations?Comments/questions about absolutely anything!Submit
