Newbeginningsbirthcenter.com

First Name_______________________ Middle Name______________________ Last Name_______________________ Prefers to be Called____________________________ Maiden Name__________________ DOB___________________ SS#_____________________________ State/Province of Birth_______________________ Age____________________ Level of Education:  8th Grade or Less  Some High School  High School Graduate  Some College, No Degree  Associates Degree  Bachelor’s Degree  Master’s Degree  Doctorate or Professional Degree Street Address______________________________________________ Apt#__________ Within City Limits?  Y  N State_______ Zip Code___________ County___________________ E-Mail Address______________________________ Home Phone______________________Cell Phone______________________ Work Phone_______________________ Religious Preference________________________ Marital Status:  Married  Single  Unmarried Couple  Separated Employer____________________________________ Occupation____________________________________________ Race:  White  Black/African American American Indian or Alaskan Native, Name of Tribe_________________  Asian Indian Chinese  Filipino  Japanese Korean  Vietnamese  Native Hawaiian  Samoan  Guamanian or Chamorro  Other Pacific Islander______________________  Other Asian_______________________  Other__________________________ Are you:  Hispanic/Latina? If yes,  Mexican/Mexican American/Chicana  Puerto Rican  Cuban  Other______________________ First Name_______________________ Middle Name______________________ Last Name_______________________ Prefers to be Called____________________________ DOB___________________ SS#_____________________________ State/Province of Birth_______________________ Age____________________ Level of Education:  8th Grade or Less  Some High School  High School Graduate  Some College, No Degree  Associates Degree  Bachelor’s Degree  Master’s Degree  Doctorate or Professional Degree Street Address______________________________________________ Apt#__________ Within City Limits?  Y  N State_______ Zip Code___________ County___________________ E-Mail Address______________________________ Home Phone______________________Cell Phone______________________ Work Phone_______________________ Religious Preference________________________ Employer____________________________________ Occupation____________________________________________ Race:  White  Black/African American American Indian or Alaskan Native, Name of Tribe_________________  Asian Indian Chinese  Filipino  Japanese Korean  Vietnamese  Native Hawaiian  Samoan  Guamanian or Chamorro  Other Pacific Islander______________________  Other Asian_______________________  Other__________________________ Are you:  Hispanic/Latina? If yes,  Mexican/Mexican American/Chicana  Puerto Rican  Cuban  Other______________________  On Medicaid #____________________________ Primary Insurance___________________________ Policy#_____________________ Group#______________________ Insurance is through:  Other______________________________________ Have you seen any other providers (i.e. a doctor or another midwife) for this pregnancy?  Yes  No If yes, Please Describe: Provider___________________________ Date of First Visit___________ # of Visits with This Provider______ 1) What forms of birth control have you used?  Pill or Mini Pill  IUD  Diaphragm  Cervical Cap  Breastfeeding  Condoms  Norplant  Natural Family Planning or Rhythm Method  NuvaRing  Depo  Withdrawal Method 2) Did you have any difficulty conceiving this baby?  Yes  No If Yes, Please Describe:_____________________ 3) Was this a planned pregnancy?  Yes  No 4) When was your last PAP smear? Month and Year______________ 5) What was the result?  Normal  Irregular If Irregular, Please Describe:_______________________________ 6) How often (how many days) do you have your period? (i.e. every 28 - 32 days)_______________days 7) How long do you bleed during your period?_________________days 8) Are your periods regular?  Yes  No If No, Please Describe:_______________________________________ 9) What was the first day of your last menstrual period (LMP)?__________________________ 10) Was this period normal for you?  Yes  No If No, Please Describe:____________________________________ 11) Are you certain about the first day of your last menstrual period?  Yes  No 12) Do you know your date of conception?  Yes  No If Yes, Please Give the Date:________________________ 13) Have you had any ultrasounds this pregnancy?  Yes  No If Yes, Please Fill in the Table Below: 14) Date_______________ Week of Pregnancy_____________ Due Date Given Based on Ultrasound_______________ 15) Date_______________ Week of Pregnancy_____________ Due Date Given Based on Ultrasound_______________ 16) Has another provider given you a due date?  Yes  No If Yes, Please Give the Date:_____________________ Please Select All That Apply (current or past):  Yes  No Chronic Hypertension (High Blood Pressure)  Yes  No Diabetes (Non-Gestational)  Yes  No Seizures/Epilepsy requiring Rx  Yes  No Gastrointestinal Disorders  Yes  No Depression or Psychiatric Disease  Yes  No Family History of Genetic Disorders  Yes  No Thyroid Disease requiring Rx  Yes  No Cervical Surgery (i.e. LEEP)  Yes  No Abnormal Cervical Cytology (PAP results)  Yes  No Prior Chemotherapy or Radiation  Yes  No Previous Bariatric Surgery  Yes  No Major Surgery of the Pulmonary System,  Yes  No Sexually Transmitted Infections/Diseases  Yes  No Alcohol or Prescription Drug Abuse  Yes  No Allergies to Medications If Yes, Please List:___________________________________________________ Please indicate if your mother or father have a history of any of the following: High Blood Pressure 1) Is this your first pregnancy?  Yes  No If No, how many times have you been pregnant before (including miscarriages, abortions or stillbirths)?___________________ 2) Have you ever had a miscarriage?  Yes  No If Yes, how many?___________ 3) Have you ever had an abortion?  Yes  No If Yes, how many?____________ 4) Have you ever had a c-section?  Yes  No If Yes, how many?_____________ 5) What was the date of your c-section?______________ What type of incision did you have?___________________ 6) Have you ever had a Vaginal Birth After Cesarean (VBAC)?  Yes  No 7) What was your pre pregnant weight for this current pregnancy?________________ 8) What is your height?____________ 9) May we have your permission to post a discreet announcement on our Facebook Group after your birth? (i.e. “A beautiful waterbirth this morning!”)  Yes  No 10) May we use modest/discreet photos of you on our website or Facebook page? (i.e. photo of midwife holding baby at postpartum check-up)  Yes  No Please Select All That Apply to Your History:  Yes  No D&C for Miscarriage or Abortion  Yes  No Cervical Incompetence/Insufficiency  Yes  No Hyperemesis  Yes  No Gestational Diabetes  Yes  No Intrauterine Growth Restriction (IUGR)  Yes  No Neonatal Death  Yes  No Placenta Previa or Placental Abruption  Yes  No Pyelonephritis (Kidney Infection)  Yes  No Rh or other Blood Group or Platelet Sensitization, Hematological or Coagulation Disorders  Yes  No Vacuum or Forceps Use  Yes  No Congenital Anomalies or Genetic Disease  Yes  No Large for Gestational Age (LGA) Baby  Yes  No Pregnancy Induced Hypertension (PIH, High Blood Pressure in Pregnancy)  Yes  No Preterm Birth (<37 weeks) or Post term Birth (>42 weeks)  Yes  No Pre-Eclampsia, Eclampsia or HELLP Syndrome  Yes  No Group B Strep (GBS) Positive Status  Yes  No Shoulder Dystocia  Yes  No Postpartum Hemorrhage Yes  No Retained Placenta or Manual Removal of Placenta  Yes  No Postpartum Depression

Source: http://www.newbeginningsbirthcenter.com/wp-content/uploads/2012/07/NBBC-Intake-Form-Revised.pdf