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Sacred Maternity Intake questionnaire
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* Indicates required question
Which package from our menu of services are you interested in?
Your answer
Name(s)/Pronouns
*
Your answer
Clients birth date and baby’s due date:
*
Your answer
Email and Phone number:
*
Your answer
Address:
*
Your answer
Partners Name, Phone number, and Email
*
Your answer
Emergency contact name, Phone number, and Relationship to client:
*
Your answer
This is a
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Singlton
Twin
Triplet
This is baby #
*
Your answer
Do you have any history of miscarriage or stillbirth?
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Yes
No
Have you ever had a C-Section?
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Yes
No
Who is your healthcare provider?
*
Your answer
Where do you plan on having your baby?
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Home
Hospital
Birth Center
Other:
What is the name of the hospital/birth center?
Your answer
Do you have any prenatal complications with this pregnancy?
*
Yes
No
If yes, check all that apply:
Group B Strep
Preeclampsia
Gestational Diabetes
IUGR
Multiples Pregnancy
History of preterm labor
STI
Other:
Do you have any other medical conditions I should be aware of, including allergies to essential oils or honey? If yes, please specify:
*
Your answer
What is your biggest fear about labor and delivery?
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Your answer
What are your feelings about labor and delivery?
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Your answer
What kinds of sounds and smells are comforting to you?
*
Your answer
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.
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Your answer
What phrases help you feel comfortable? Either spoken to you or when you say them to yourself?
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Your answer
Where do you usually hold tension in your body?
*
Your answer
How would you most like to be supported during labor?
*
Your answer
Anything you would like to add?
Your answer
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