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New Client Intake Form
I would love to learn a little bit about you before our visit together. Please fill out this form to the best of your ability.
Thank you!
Leah Pinault
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Email
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Your email
Name
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Your answer
Phone Number
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Your answer
Email
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Your answer
Home Address
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Your answer
Your Age
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Your answer
Your Occupation
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Your answer
Partner's Name, if applicable
Your answer
Partner's Phone Number
Your answer
Partner's Email
Your answer
Partner's Occupation
Your answer
Care Provider
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Your answer
Birth Location (with address)
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Your answer
Estimated Due Date
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MM
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DD
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YYYY
Sex of Baby(s)
Boy
Girl
No gender
It's a surprise!
Other:
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Planned Method of Feeding
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Breastfeeding
Formula
Mixed feeding, may include pumping, breastfeeding and/or formula
Not sure yet
Would you like to share information on previous pregnancies?
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Your answer
Have you given birth before? How was your experience?
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Your answer
Any personal health concerns / allergies I should be aware of?
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Your answer
How has your pregnancy been thus far? Please let me know of any complications, restrictions, medications, etc. specific to this pregnancy.
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Your answer
Have you taken any childbirth ed classes yet? If so, what?
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Your answer
What does your ideal birth experience look like?
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Your answer
What do you anticipate will be your greatest source of strength/comfort while in labor? What comforts you when you are not feeling well or are anxious?
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Your answer
What do you anticipate will be your greatest challenge while in labor? Do you have any concerns / anxieties?
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Your answer
Do you need any referrals for your physical comfort during your pregnancy (acupuncturist, nutritionist, chiropractor, physical therapist etc)?
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Your answer
Is there anything else you think I should know?
Your answer
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