Sacred Maternity Intake questionnaire 
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Which package from our menu of services are you interested in?
Name(s)/Pronouns *
Clients birth date and baby’s due date: *
Email and Phone number: *
Address: *
Partners Name, Phone number, and Email *
Emergency contact name, Phone number, and Relationship to client: *
This is a *
This is baby # *
Do you have any history of miscarriage or stillbirth? *
Have you ever had a C-Section? *
Who is your healthcare provider? *
Where do you plan on having your baby? *
What is the name of the hospital/birth center?
Do you have any prenatal complications with this pregnancy? *
If yes, check all that apply:
Do you have any other medical conditions I should be aware of, including allergies to essential oils or honey? If yes, please specify:  *
What is your biggest fear about labor and delivery? *
What are your feelings about labor and delivery? *
What kinds of sounds and smells are comforting to you? *
When you are in pain what types of personal comforts do you like to use? Eg. A quiet room, dim lighting,
heat, cold, words of affirmation, etc.
*
What phrases help you feel comfortable? Either spoken to you or when you say them to yourself? *
Where do you usually hold tension in your body? *
How would you most like to be supported during labor? *
Anything you would like to add?
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