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INTAKE FORM
Client Profile
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* Indicates required question
Name (First and Last)
*
Your answer
Email
Your answer
Age
*
under 20
20 - 30
30 - 40
over 40
Racial demographic
*
Native American
White/Caucasian
Black/African American
Hispanic/Lantinx
Asian
Multiracial
Expected Due Date
*
MM
/
DD
/
YYYY
Phone number
Your answer
Address
Your answer
Has your due date been changed?
Yes
No
Clear selection
If Yes, Why?
Your answer
Do you have insurance?
*
Yes
No
Who is your insurance provider?
Your answer
Gender of baby
Female
Male
Waiting
Clear selection
Who will be present at birth?
Your answer
Do you plan to write your birth preferences?
yes
No
Clear selection
Will you need help writing your birth preferences?
Yes
No
Clear selection
How do you plan to feed baby?
*
Your answer
Do you have any questions or concerns about child birth or breastfeeding?
Your answer
Total number of pregnancies
Your answer
Number of live births
Your answer
Name(s) and age(s) of child(ren)
Your answer
Previous pregnancy complications/discomforts and treatments
Your answer
Current pregnancy complications/discomforts and treatment sought
Your answer
Do you have any allergies, sensitivities or diet restrictions?
Your answer
Medications you are taking (including prenatal vitamins):
Your answer
Does anyone in the home smoke?
Yes
No
Clear selection
If yes, Who?
Your answer
Currently receiving care for any medical condition (not pregnancy) or a contagious diseases?
Your answer
Where do you plan to deliver?
*
Your answer
Care Provider?
*
Your answer
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