Intake Form CLIENT INFORMATION Name * First Name Last Name Estimated Due Date * MM DD YYYY Place of Birth * Provider Name Have you taken a tour of your birthing location? Yes No Who will be attending your birth? * PREGNANCY HISTORY Previous Pregnancies Previous Births Child(ren) Name(s) and Age(s) Any Previous Complications? CURRENT PREGNANCY Have you been diagnosed with any of the following medical conditions during this pregnancy? Check all that apply Pre-eclampsia Gestational Diabetes Group B Strep Anxiety Depression Rh Incompatibility Heartburn Severe Insomnia Back, sciatic, or pubic pain Headaches Pica Gestational High Blood Pressure Anemia Hyperemesis Gravidarum Placenta Previa Vena Cava Compression Other MEDICAL HISTORY Allergies Food and/or Medications Diagnosed Health/Medical Conditions Current Medications, Vitamins, and Supplements (please include herbs and essential oils if applicable OVERALL WELLBEING How has sleep been during pregnancy? Please include herbs and essential oils if applicable How did you hear about Beauty In Birthing? * Tell us more about your support needs and anything else you want us to know! * EXPECTATIONS What do you anticipate will be your greatest challenge? (during pregnancy, early labor, or birth) What do you anticipate will be your greatest strength? (during pregnancy, early labor, or birth) What are your fears or concerns regarding pregnancy, early labor, and/or birth? What do you find comforting? (what type of environment, music, meditation, etc.) What type of support would you like from a birth doula? Is there anything you would not want? What is the most important thing for you and your partner regarding birth doula support? What do you envision for your labor and delivery? Please describe what you would like your birth to look like and feel for you. (try to use at least 5 descriptors, for example, peaceful) PAIN MANAGEMENT Please indicate which comfort measures, tools and movement you would like to use during labor. Check all that apply. Physical Movement / Positions / Walking Massage and/or Acupressure points Rebozo techniques Guided breathing techniques Heating pads and/or cold compress Music and/or dancing TENS machine Counterpressure (by doula or partner) Other (please indicate any other pain management techniques that you would like to discuss) Pain Medication (please indicate which pain medication you would like to use during labor. Check all that apply. Epidural Nitrous oxide Narcotic pain relief EARLY LABOR PREFERENCES While At Home - (please indicate which items you prefer during early labor. Check all that apply. Labor at home as long as possible Distractions as long as possible Affirmations Dim lights Aromatherapy Birth Ball Shower / Bath While in the Hospital- (please indicate which items you prefer during early labor. Check all that apply. Wear my own clothing /gown Continue eating Ice and/or popsicles available Vaginal checks at my request/limited Vaginal checks frequency based on HCP protocol Distractions as long as possible Affirmations Continuous Fetal Monitoring Dim lights Aromatherapy Birth Ball Saline lock or IV Saline lock placed in forearm not hand ACTIVE LABOR PREFERENCES Please indicate which items you prefer during active labor. Check all that apply. No loud voices / noises when entering my room Move as much as possible Try different pushing positions Perineal Massage Warm Compress on Perineum No Episiotomy / Tear Naturally Partner to catch the baby (with HCP assistance) POST BIRTH PREFERENCES Please indicate which items you prefer after your baby is born. Check all that apply. Delayed cord clamping Wait until the cord stops pulsating Keep my placenta Immediate skin to skin Delay newborn procedures No routine Pitocin unless hemorrhaging Birth placental without traction NEWBORN PROCEDURES Please indicate which procedures you would like for your baby. Check all that apply. Eye ointment Vitamin K shot Standard vaccinations All newborn procedures done skin to skin Exclusively breastfeeding Do not offer by baby a pacifier or sugar water I want my baby circumcised in the hospital THE FOURTH TRIMESTER Do you have any fears or concerns regarding the fourth trimester (three months after birth) What type of support do you have in place for the fourth trimester (meal train, errands, cleaning, etc.)? Have you and your partner discussed a policy regarding guests during the fourth trimester? ANYTHING ELSE Please feel free to share anything else that I may have missed asking about. I look forward to being apart of your support team! Thank you!You will be contacted within 24 hours. Have a Beautiful Day!
