Name
*
First Name
Last Name
Preferred Name, Pronouns
Email
*
Phone
*
(###)
###
####
Partner/Spouse Name
First Name
Last Name
Partner/Spouse Preferred Name, Pronouns
Partner/Spouse Email
Partner/Spouse Phone
(###)
###
####
Address
*
Please include info on where I should park when visiting you.
Estimated Due Date or Baby's Birth Date
*
MM
DD
YYYY
Primary Midwife/OBGYN & Delivery Location
*
If already delivered, did you experience any complications with your pregnancy and/or birth? (i.e. tearing, unplanned cesarean, premature birth, ICU/NICU admission, preeclampsia/eclampsia, etc.)
What is your planned method of feeding? (breast/chest feeding, pumping, formula, etc.)?
*
What does your current diet consist of?
*
What are some of your biggest concerns about the postpartum period?
*
How would you describe your and your partner/spouse's personalities?
*
Are there any identities that are important to you and/or your partner/spouse? How do you expect these identities to play a role in your labor/birth and postpartum experience?
*
Are you seeing any wellness practitioners for regular care? (chiropractor, acupuncturist, naturopathic doctor, etc)
*
What is your current stress level? In what ways do you deal with stress in your life? What helps you to feel calm and grounded?
*
What does your family and support system look like?
*
Any allergies or medical conditions I should know about?
*
Is there anything else you would like me to know?
How did you find me? If a referral, who referred you to me? I'd love to thank them.
*