Client Intake Form – Baby Bumps and Beyond

Your Name*

First NameLast Name

Your Phone Number*

Area CodePhone Number

Your Birth Partner's Name

First NameLast Name

Your Birth Partner's Phone Number

Area CodePhone Number

Your Home Address*

Street

House Number

City

Postal / Zip Code

Your Email *

example@example.com

Your Birth Partner's Email

example@example.com

Estimate Due Date*

Date

Doctor/ Midwife's / Practice name*

Delivery Location

Planned Method Of Feeding

BreastfeedingFormula FeedingCombinationNot sure but I would like more information

Are you currently experiencing any specific health or other concerns that affect this pregnancy? As with all of your information, anything you share will be kept confidential.*

Explain any complications you have had with this pregnancy or any restrictions your caregiver has given you. *

Have you given birth before?*

NoYes, Vaginally onlyYes, Cesarean OnlyYes, Vaginally and Cesarean

Do you have a history of miscarriage or infant loss?

YesNo

Have you taken or are you planning on taking any childbirth education classes?*

Please list any other classes you have taken or plan on attending.

Who do you plan to have assist you with your labor?*

Have you written a birth plan?*

Yes, it is a final copy.Yes, but it is a draft and I would like some help.No, I would like like help writing one.No, I have no interest in one.

In 5 words, please describe how you would like to FEEL and how you would like your birthing space to feel? (ex: calm, peaceful, energized, happy)

Are there any cultural/religious choices/preferences for your birth that I should know about?

Have you talked about your birth preferences with your caregiver?

How do you feel about interventions in labor/delivery?

What type of pain management would you like to use?*

What type of comfort measures would you like to use in labor?*

Please list any questions you have or topics you would like to discuss:

Just a little paperwork…

Current Pregnancy Information

Pregnancy History

Birth Preparation