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Namaste Healing Body Balancing Intake
* Indicates required question
Email
*
Record my email address with my response
Name
*
Your answer
Phone number
*
Your answer
Height
Your answer
Estimated Due Date:
MM
/
DD
/
YYYY
Number of previous births
Your answer
What is your reason for coming in today?
*
Your answer
If you have discomfort, please describe in detail if possible. (i.e. dull ache in the low pelvis when lying on my left side)
Your answer
Who is your primary care provider in the pregnancy?
Your answer
Where are you planning to deliver?
Your answer
How did you find us?
Your answer
Please check any of the following you have or have had in the past. (I know it's a long list...thank you for going through it for me.)
*
hypertension
Threatened preterm labor
glaucoma
Placenta previa
Placenta accreta
Diastasis recti
anterior placenta
Work related body position requireme
bed rest
Vaginal bleeding
Pelvic pain
heartburn
Anomalies with baby
constipation
twins
Sports injuries
dizziness
headaches
Previous cesarean birth
Assisted Reproductive Technology
Bicornate uterus
Wear high heels
Lower back pain
Other previous injuries (accident, etc.)
None of these
Other:
Required
Besides body balancing, is there anything else you'd like to discuss today?
vaginal breech birth
advocating for options / home
advocating for options / hospital
planned cesarean
going into labor before cesarean birth
VBAC
research and resources
ECV
Other:
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