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New Client Intake
Name
*
First
Last
Phone Number
*
Email
*
Physical Address
*
Line 1
Line 2
City
State
Zip Code
Country
Occupation
*
Partner's Name
*
First
Last
Partner's Phone Number
*
Expectant Mother's Date of birth
*
Estimated Due Date
*
Care Provider
*
Family Doctor
Roots Community Midwives
Other Midwives
OB
Shared care- Midwifery and OB
Planned place of birth
*
Home
Squamish General Hospital
Lion's Gate Hospital
BC Women's Hospital
Other
Partner's Occupation
*
Do you have any of the following health concerns?
*
Asthma
Gestational Diabetes
Type 1 Diabetes
Type 2 Diabetes
Pre-eclampsia
Heart disease
Bleeding disorders
High blood pressure
Low blood pressure
Endometriosis
Hepatitis
Herpes
HIV
MRSA (carrier)
Anxiety
Depression
Although I ask for medical history, I do NOT perform or manage any clinical issues. This history is simply to help me support you in your labor, birth, and postpartum
Do you have any food, scent, or latex allergies?
*
Is this your first pregnancy?
*
Yes
No
If no, please briefly describe any prior pregnancies
*
If you have previously given birth, please briefly describe: Length of labour(s), people who supported you, interventions used (ie: pain medication, forceps)
*
Do you plan to breastfeed?
*
Yes
No
Undecided
Sex of baby, if known
*
Girl
Boy
Have you attended prenatal classes? If so, where?
*
Briefly describe your expectation of Doula support
*
Briefly describe any worries or special concerns you have for your upcoming birth
*
Are you interested in learning more about a Birth Photography package?
*
Yes
No
Where did you hear about us?
*
Facebook Page (Micheline Walkey Birth Doula)
Facebook Group (Squamish Moms)
Instagram (@michelinewalkey_birthdoula)
Print or Community Ad
Word of mouth
Other
Submit
Home
Meet Micheline
Services
TENS Rental
Birth Photography
Blog
Resources