Whole Spirit RiverdaleClient Intake FormClient Intake Form First * Last * Partner's Full Name (If Applicable) Street Address City Zip Code Preferred Phone Number * Email * Do you prefer calls, texts, or emails? * Phone Calls Text Messages EmailsPrivacy Policy:All of your personal information will be kept private and will never be shared with anyone and will be used solely to help me best support you. It is your responsibility to share any and all relevant medical information with your healthcare provider. Baby's Due Date * This is baby # * Do you have a history of miscarriage or stillbirth? * Yes NoHave you received fertility treatments? * Yes No If YES, for how long? Have you ever had a C-Section? * Yes No If YES, for what reason(s)? Have you had any prenatal complications with this pregnancy? * Yes NoIf YES, check all that apply: Group B Strep Preeclampsia Gestational Diabetes IUGR Multiples Pregnancy Preterm Labor STI Other If you checked "STI" or "Other", please specify: Do you have any other medical conditions I should be aware of, including allergies to essential oils or honey? * Yes No If YES, please specify: Who is your care provider? * MidwifeObstetricianGeneral Practitioner Name(s) of your care provider(s) * Where do you plan to have your baby? * HomeHospitalBirth Center Name of the Hospital/Birth Center What are your feelings about labor and delivery? * What is your biggest fear about labor and delivery? * If you could labor and deliver your baby anywhere in the world, in any setting, not having to worry about the safety of you or your baby, where would your fantasy birth take place? * 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? * What phrases help you feel powerful? Either when spoken to you or when you say them to yourself. * Where do you usually hold tension in your body? * How would you like to be supported during labor? * Is there anything else you would like to add? Printed Name - Client's * Today's Date * If you are human, leave this field blank. Submit
