Intake Form — Shout of Joy Birth

Email

Mother's Occupation

Delivery Address and Providers Name

Ages of Other Children and Plan for Childcare

Any additional people at delivery? Any tricky family dynamics to consider?

Back Up Hospital if Transferred (emergent and non- emergent)

Estimated Due Date? Did you have an early dating ultrasound and if so, is this date from that US?

Are you working with any other care providers? Chiropratic, pelvic floor, etc

Any High Risk Factors?

Do you require a specific diet? Any food allergies or avoidances?

Are you taking any medication? Any Allergies?

Prior Pregnancy Intake

If yes, please state number of pregnancies and outcome of each one.

Example: Pregnancy One: Miscarriage at 12 weeks Pregnancy Two: Vaginal Delivery at 41w3d

Please describe previous birth experiences

Feel free to include weeks gestation, length of labor, complications, place of birth, medications, emotional/physical response to birth, care providers, support team, and any other details you wish to share. Be sure to include anything that you want avoided or repeated at this birth.

Education and Family Culture

Have you taken a birth education class?

When you consider your upcoming birth describe how you feel and what kind of an experience you hope to have.

Do you have any worries, fears, or anxieties about this pregnancy?

Feel free to include any life stressors that are contributing to any worries.

Do you have any physical or mental health concerns that may impact your pregnancy, birth, or postpartum recovery?

Feel free to include any emotions you have about your body during pregnancy, delivery, or postpartum.

Do you have any specific cultural, philosophical or spiritual beliefs or traditions that you would like to be honored and respected during this birth?

What are your feelings regarding medical pain relief and interventions during labor and birth?

Stress Management

How do you relax after a long day?

Where do you hold tension?

How do you sit or rest through out the day? How do you sit when relaxing? How do you position yourself while sleeping?

Any additional thoughts or concerns you would like me to know?

Photo Release

During labor and delivery, I will attempt to snap some photos when I am able. I send all photos to you after delivery so you have a few special ones. Additionally, it helps me promote my business to share photos on my social media accounts. I will never share photos of baby's face or your private parts.

Client Intake Form