Love In Motion Client Intake Form

Dearest mama,

Thank you so much for helping me get to know you better with this information. What you provide to me is confidential, safe and secure. I will not share nor sell any of your information to others, including third parties. I look forward to getting to know you and your family and am excited to discover ways to make your birth experience a positive and memorable one!

About You

Name

First Name Last Name

Date of Birth

Month Day Year

E-mail

Contact Number:

Area Code Phone Number

Marital Status

Partner's Name, if applicable

First Name Last Name

Partner's Phone Number, if applicable

Area Code Phone Number

Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

In case of emergency...

Emergency Contact:

First Name Last Name

Relationship

Contact Number

Area Code Phone Number

Taking any medications, currently?

Yes No

If yes, please list it here

Any medical conditions/allergies I should know about?

Yes No

If yes, please explain here

Estimated Due Date

Date

Faith/Religion

How did you hear about me?

Where are you giving birth?

Who is your OB/GYN or Midwife?

Who do you plan on having attend your birth?

About Your Baby

Are you expecting...

What method of conception is this pregnancy?

Natural IUI IVF Sperm Donor Egg Donor

Is this your first pregnancy?

Yes No

If not, please explain your obstetrical history:

Total pregnancies

Miscarriages

Abortions

Births

C-Sections

VBAC

If applicable, briefly describe any prior pregnancies or births including weeks gestation, length of labor, birth weight, medications, emotional and physical ease of birth, and anything else you would like to tell me.

If applicable, did you have any complications after any other births, miscarriages or abortions (pain, infection, emotional trauma)?

Yes No N/A

If yes, please explain:

About Your Health

How do you typically handle stress or change of plans?

What helps you relax or feel better?

List the names and ages of your older children and/or pets.

Describe your emotions surrounding this pregnancy.

Have you been told you are a high-risk pregnancy?

Yes No

Describe any bouts of depression you have had, the length of time for which you experienced it, how long it has been an issue, and any medication you take for it. If you are off medication due to the pregnancy, how has this affected you?

Share your postpartum plans as you now know them.

Do you have any past or current life issues in which you feel may affect the course of your birth?

Yes No

If yes, do I have your permission to discuss this with you?

Yes No

Describe your current physical health.

What kind of work do you do? How do you feel about it?

How much time do you plan on taking time off work for postpartum?

Describe your nutritional intake during your pregnancy. ALSO, do you have any food allergies, intolerances, sensitivities, or preferences?

Describe how you move your body on a daily/weekly basis (exercise, active lifestyle, sedentary, etc.)

Preparing for Birth

What are your hopes, desires, wishes for your upcoming birth?

What fears or concerns do you and/or your partner have surrounding birth?

What are your thoughts regarding medical pain relief and interventions during labor and delivery?

What is your impression of your care providers' feelings regarding medical pain relief and interventions for your labor and delivery?

Are you planning on attending a childbirth and/or newborn class? I recommend taking at least a newborn class

Yes No

Doula Support

What are your expectations for our prenatal visits?

Please describe anything you specifically want to learn from our visits?

What do you hope to teach me in our prenatal visits that will be pertinent to your labor and delivery experience?

What is your ideal vision of me as your doula at your birth?

Would you like me to use aromatherapy during labor? If yes, describe your favorite oils to use.

Yes No

Photography

Would you like me to help with some candid photography or videography at your birth?

Yes, graphic is ok Yes, non-graphic photography please No

I am interested in learning more about the following services:

Childbirth Classes KT Tape Support for pain & swelling Postpartum Support Planning Postpartum Belly Binding

Is there anything else you would like me to know that may affect this process in order to provide you the proper care?

New Birth Client Intake