vine & co. intake form GENERAL INFORMATION Name * First Name Last Name Date of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone - Primary * (###) ### #### Email * Support Person Name First Name Last Name Phone - Support Person (###) ### #### Due Date * MM DD YYYY Gender of Baby * Boy Girl We don't know yet! If you don't know yet, are you waiting to be surprised at birth? Yes! Not Necessarity N/A Birth Location * Provider Type * OBGYN CNM - Certified Nurse Midwife CPM - Certified Professional Midwife Family Practitioner Still Deciding Name of OB/Midwife Group * Name of Hospital or Birth Center * Address of Hospital or Birth Center * Address 1 Address 2 City State/Province Zip/Postal Code Country If planning a home birth, what is the transfer hospital name? Is your provider aware that you are hiring a doula? * Yes No Are you or do you plan on seeing a chiropractor during your pregnancy? yes no would love resources for chiropractors What is your occupation? * What do you like to do for fun? * Do you have a regular rhythm of exercise? * Yes No If "Yes", what kind and how often? Modesty Level * 1 - Don't care at all about modesty 2 3 4 5 - Care very deeply about modesty How comfortable are you with physical touch? * 1 - Uncomfortable. Please ask first. 2 3 4 5 - I am very comfortable with touch Do you have a sensitivity to fragrances/essential oils? * Yes No If "Yes", please explain CURRENT PREGNANCY & BIRTH What number pregnancy is this? * What number birth would this be? * Have you experienced any complications with this pregnancy? * Do you feel supported by your provider? * Have you taken a childbirth education class? * Yes Not Yet If "Yes", what is the name of the course that you took? What information has been helpful from this class. Is there any questions I can help clarify? Do you want me to take photos or videos at during your birth? * Yes, both photos and videos are welcome Yes, only photos Yes, only videos No If all the stars aligned, please describe your dream birth experience. * Include things that are most important to you What are your thoughts about pain management? * Are there any spiritual elements that you would like present during your birth? What type of support do you envision from your support person, doula, and care provider * Please include separate descriptions for each individual Are there any referrals or resources that you would like from me at this time? Is there anything in your personal history that you anticipate may make it hard for you to cope with the experience of labor and/or nursing? Please share any fears or concerns that you have regarding your birth experience PREVIOUS PREGNANCIES AND BIRTHS If this is your first pregnancy/birth you may skip this section How was your pregnancy/pregnancies Please include a description for each previous pregnancy How was your labor(s)? How long did you push? Please give details of any previous birth experiences, good and bad Did you experience any "baby blues" or postpartum depression? How did you feed your baby? What were a few things you loved about your birth? What would you like to be different with this birth? POSTPARTUM How do you plan on feeding your baby? * Do you feel like you have community around you to support you postpartum? * Yes No If "No", explain What fears or concerns do you have post-delivery? Are there any other questions or pressing topics that are important to discuss before your birth? Thank you for taking the time to fill out the intake form!
