New Client Intake & Medical History Form

New Client Intake & Medical History Form
This form takes about 30 minutes to complete. Please make sure to complete all required fields as this information helps me to best serve your family.
Client Full Name*
First NameMiddle NameLast NameSuffix
Client Preferred Name
Client Preferred Gender Pronouns
Client Birth Date*
MonthDayYear
Marital Status*
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Home Phone Number
Area CodePhone Number
Work Phone Number
Area CodePhone Number
Mobile Phone Number*
Area CodePhone Number
E-mail*
What's the best way to reach you outside of our prenatal/postpartum sessions? (phone calls, text message, emails, etc.) Are you opposed to receiving regular phone calls?
How were you referred to me? Or, how did you find out about my services?*

Partner Information
Partner's Full Name
First NameMiddle NameLast NameSuffix
Partner Preferred Gender Pronouns
Address (if different than client)
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Partner's Phone Number
Area CodePhone Number
E-mail
example@example.com
Occupation
Industry

Provider and Birth Location
Provider First and Last Name (OB/GYN, Nurse Midwife, etc.)
Where do you plan to give birth?*
HospitalBirth CenterHomeOther
Name of Hospital or Birth Center*
Address of Birth Site (skip if same as client home address)
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry

Client Health History
1. Allergy or Sensitivities*
Propensity is when several members of family have allergy or intolerance
First Known Date
MonthDayYear
Product
Reaction
2. Allergy or Sensitivities
Propensity is when several members of family have allergy or intolerance
First Known Date
MonthDayYear
Product
Reaction
3. Allergy or Sensitivities
Propensity is when several members of family have allergy or intolerance
First Known Date
MonthDayYear
Product
Reaction

Social History
Smoking Status*
Alcohol Use*
Current Alcohol UserFormer Alcohol UserAlcohol UseThis PregnancySocial Drinker or Never Drink Alcohol
Drug Use (includes: prescription or OTC drug abuse; THC; cocaine; heroin; methamphetamines, etc.)*
Current Drug UserFormer Drug UserDrug Use This PregnancySocial drug user or Never a Drug User
Nutrition*
Example: Vegan or Sugar Free
Exercise Habits*
Sleep Habits*
School/Work*
Hobbies*

Client Additional Information