Client Intake Form Pregnant Person's Information Full Name * First Name Last Name Preferred Pronouns Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Email Address * Date of Birth * MM DD YYYY Profession Partner/Support Person Full Name (if applicable) Partner/Support Person Phone (###) ### #### Birth Information Estimated Due Date * Care Provider * Birthing Location * i.e. Home, Birthing Center or Hospital Birthing Location Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Have you toured the birthing location? Yes Not Yet It's at home Have you taken a prenatal class? Yes No, but plan to. No, and don't plan to. Medical History Pregnant Person's Health History Please list: Condition, Date, Treatment, Response to Treatment. Current Medications/Supplements Number of Pregnancies * Number of Children Last Date of Menstrual Cycle Do you have any allergies or sensitivities (food/medication)? Any food preferences? How many hours of uninterrupted sleep do you get at night? Do you feel well rested? Are you taking naps during the day? Explain your prenatal experience so far, emotionally and physically. Any Medical Conditions Developed During Pregnancy? Check all that apply. None Gestational Diabetes Group B Strep Severe Insomnia Anxiety Depression Heartburn Headaches Back Injury/Pain Hyperemesis Gravidarum (severe morning sickness) Herpes Anemia Family Medical History Mother, Father, Grandmother (M), Grandfather (M), Grandmother (P), Grandfather (P), Siblings. Childbirth Education Are you taking childbirth education? If so, where and when? What would you like to learn in a childbirth class or from our sessions? Are you and/or your partner/support person reading any books or listening to any podcasts about labor, postpartum or breastfeeding/chestfeeding? Please note any topics you want to discuss further: Select all that apply. Stages of Labor Natural Comfort Strategies Positions for Labor Breathwork Practices Timing Contractions Unmedicated and Medicated Induction Common Medical Procedures Used in Labor Pain Medications Used in Labor Episiotomy Cesarean Birth Assisted Vaginal Birth Postpartum Healing Feeding and Breastfeeding/Chestfeeding Newborn Care Postpartum Nutrition Ayurvedic Medicine Yoga and Breathwork Practices Do you plan to take any other classes to prepare (i.e. newborn care, infant CPR, breastfeeding/chestfeeding, etc)? Labor and Birth Preferences What is your birth vision and preferences? Have you shared your preferences with your care provider? Have you discussed protocols if you go past your estimated due date? When does your care provider want you to call them/arrive at the birthing location? If birthing at home, when does your midwife want to join you? In what ways are you preparing for this labor, birth and postpartum (i.e. meditation, exercise, etc)? What do you anticipate will be your greatest challenge while in labor? What do you anticipate will be your greatest source of strength while in labor? In previous painful situations (i.e. sickness, injury, headache, surgery), what methods have been helpful and comforting for you? Do you have any fears or concerns around labor, birth and/or postpartum? In what ways do you hope a doula's support will be helpful to you? What types of assistance do you imagine will be most useful for you? How does your support person want to be involved in your birth (i.e. hands on, share support with the doula, or let the doula take the lead)? Who would you like to be present during your labor? Check all that apply. Partner Children Doula Friends Other Family Members Other Please select the pain management or relaxation techniques that you would like to try Select all that apply. Massage Acupressure Aromatherapy Meditation Guided Breathwork Visualization Chanting Heating pads Cold packs Music Therapy Herbal Support Do you want any of the following non-medical choices during labor? Select all that apply. Labor at Home Labor in Hospital or Birthing Center Fluids Ice/Popsicles Food Walking Shower/Jacuzzi Birthing Tub/Pool Rocking Chair Birth Ball Wear Own Gown Dim Lighting Do you want any of the following medical choices for early labor? Select all that apply. Continuous Fetal Monitoring Intermittent Fetal Monitoring No IV or Heparin Lock IV Vaginal checks limited to as few as possible Vaginal checks done per HCP/Staff protocol Medications offered (i.e. epidural) Medications not offered Narcotics Do you want any of the following to occur for the birth? Select all that apply. Pictures Video Birth Parent chooses birth positions HCP choose birth positions Perineal Massage Episiotomy Prefer to tear over episiotomy Cord Cut by Partner Cord Cut by Care Provider Delay Cord Cutting Baby Caught by Partner with HCP help Announce the sex of baby Place Baby on Birth Parent's chest immediately Baby cleaned before given to Birth Parent Delay newborn procedures for one hour Birth of Placenta without Pitocin Save Placenta Please share anything else you would like me to know about you, your preferences or any topics you would like to discuss. Photo Release I understand that Adrienne Diaz practices photography, and that photos taken during labor, birth and reproductive events, with my permission and if the situation allows, are for educational and advocacy purposes only. I grant the doula and Ho’ola Mamma permission to take, use, re-use, publish, and republish pictures of me in which I may be included, in whole or in part. Yes, I consent! You may use (non-explicit) pictures of me and my baby with my approval. No, thank you. I would like to keep the photos private. Thank you!
