Prenatal Intake Sheet
Date______
About YouName______DOB______
Occupation ______Place of Work ______
Work Phone______Email ______
Partner______DOB ______
Occupation ______Place of Work ______
Work Phone ______Email ______
Home Address ______
City ______State ______Zip ______
Directions ______
______
Home Phone ______Cell Phone ______
How long have you been together______
Siblings names and ages______
Others who live in your household______
Plan of care for children during labor ______
Plan of care for pets during labor______
People you will have attend your birth ______
Referred you?______
About Care ProvidersPrimary Provider ______
Type of Practice (Private, Group, HMO)______Phone______
Back Up Provider ______
Place of Birth ______Phone______
Home Birth Backup Hospital ______Phone______
Tour? ______Registered ______
Pediatrician ______Phone______
Childbirth Classes ______With Whom ______
Breastfeeding Classes______With Whom ______
Other Classes ______
Other Health Care Providers You See ______
Support InformationFears/Concerns about Pregnancy______
Fears/Concerns about Birth ______
Trust caregivers? ______
Trust Hospital/home birth ______
Age Concerns______
Partner Attending Birth? ______
Reason wanting a doula______
Prenatal Intake Page 2
Name______
Health HistoryGeneral Health______
Pregnancy Health______
Special Concerns ______
Allergies (drugs, food, latex)______
Diet______
Vitamins ______Supplements ______
Routine Meds including OTC ______
Drink/Smoke/Drugs______Quantity/Frequency______
Exercise/Frequency______
Medical History Check any applicable:
___ Anemia___ Asthma ___ Anorexia/Bulimia ___ Bladder/Kidney Infections
___ Bleeding Disorders ___ Cancer ___ Conization/LEEP ___ Diabetes ___ Epilepsy
___ Fibroids ___ Heart Disease ___ Hepatitis ___ Herpes ___ HIV ___ Hypoglycemia
___ Hyper/Hypotension ___ STD’s ___ TB ___ Thyroid Disorders ___ Ulcers
___ Varicosities ___ Vaginal Infections
Any major surgeries, injuries, hospitalizations ______
History of emotional problems ______
______
Any history of personal trauma (rape, abuse, etc) ______
______
Your PregnancyPre-pregnancy PMS ______Pain/Cramping______
Coping techniques ______
Planned Pregnancy______Feelings Now ______
Difficulty Conceiving ______Special technology used ______
Pregnanies ______Miscarriage ______Live Births ______
Prior Pregnancies:
Date / #Week / Sex / Weight / Name/Outcome / Labor length / Meds, Intv, Compl.Have you breastfed before? Problems? ______
Have you ever had postpartum depression? ______
Prenatal Intake Page 3
Name______
Check any that apply:
___ Acid Indigestion ___ Anxiety ___ Carpal Tunnel Syndrome ___ Bowel Problems
___ Fatigue ___ Hemorrhoids ___ Incontinence ___ Lack of Sleep ___ Muscle Cramps
___ Nausea/Vomiting ___ Shortness of Breath ___ Swelling/Edema
Any complications______
Prenatal Screening
Had an ultrasound?______How many______Results ______
Other prenatal screening ______
Group B Strep?______Gestational Diabetes ______
About Your BirthWhat is your vision for this birth ______
What are your expectations of your doula? ______
Where in your body do you usually feel tension? ______
How do you manifest tension:
___ difficulty breathing ___ sweating ___ panic ___nausea ___ moaning
___ grinding teeth ___clenching fists ___ racing heart ___ anxiety ___ other______
How do you comfort yourself when experiencing stress or pain:
___ distraction ___ movement ___ silence ___turning inward ___ self-medicating behaviors
___ OTC drugs ___ hot/cold packs ___ companionship ___ other ______
What is your plan for coping with the pain of labor? ______
How do you feel about medical procedures/intervention in birth? ______
Prenatal Intake Page 4
Name______
How would you like your doula to respond if you are requesting pain medications? ______
Do you have a birth plan? ______Signed by caregiver? ______
Are you wanting photography/video? ______
Who will be taking pictures/video? ______How graphic? ______
Anything else I should know to support you?
______
Are there any cultural/religious choices/preferences that may affect your birth?
______