Love In Motion Client Intake Form

New Birth Client Intake

Thank you for helping me get to know you better with the below information. What you provide to me is confidential, safe and secure. I do 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 NameLast Name
Nickname, if applicable
Any special pronunciation of your name
Date of Birth

MonthDayYear
E-mail
Your Phone Number:

Area CodePhone Number
Marital Status
Partner's Name, if applicable

First NameLast Name
Nickname, if applicable
Partner's Phone Number, if applicable

Area CodePhone Number
Do you prefer communication to be mostly via text or phone?
In case of emergency...
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
Please list any current medications and/or supplements you are currently taking.
Any medical conditions/allergies I should know about?

YesNo
If yes, please explain here
Estimated Due Date

MonthDayYear
Date
Faith/Religion
How did you hear about me?
Where are you planning on giving birth?
Who is your OB/GYN and/or Midwife?
Who do you plan on having attend your birth?
About Your Baby
Are you expecting...
What method of conception is this pregnancy?

NaturalIUIIVFSperm DonorEgg DonorOther
Is this your first pregnancy?

YesNo
If not, please explain your obstetrical history:
Total pregnancies
Miscarriages
Abortions
Vaginal Births
Cesarean Births
VBAC
If applicable, briefly describe any prior pregnancies/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)?

YesNoN/A
If yes, please explain:
About Your Health
How do you typically handle stress or change of plans? During birth, how do you see yourself handling a possible change in plan(s)?
What helps you relax or feel better?
If applicable, 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?

YesNo
If yes, Why?
Share your postpartum plans as you now know them.
Do you have any past or current life trauma or things in which you feel may affect the course of your birth?

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

YesNo
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?
Do you have any food or otherwise allergies, intolerances, sensitivities, or preferences?
Describe how you move your body on a daily/weekly basis (exercise, active lifestyle, sedentary, etc.)
How would you best describe your communication style? Please explain.
Ex: Analytical, Big Picture/Cliff notes, Small Picture/Step-by-step, Emotional language, Human Connection, Problem Solver, Just Facts, etc.
Do you take direction well or prefer to work through things on your own with little guidance? Please explain.
How do you like to receive information?
News Reels, Podcasts, Social Media (IG, FB, etc), YouTube, online research, 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?
Referring to the pain medication scale below, on a scale of +10 to -10, what is your medication preference?
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

YesNoOther
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.

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

Yes, graphic is okYes, non-graphic pleaseNo, thank youOther
I am interested in learning more about the following services:

Childbirth ClassesKT Tape Support for pain & swellingPostpartum Support PlanningPostpartum Belly BindingHypno Birth RehearsalPlacenta EncapsulationPostpartum DoulaUnmedicated Birth Prep
Is there anything else you would like me to know that may affect this process in order to provide you the proper care?
Should be Empty:

New Birth Client Intake