Child intake At any time you may save and return to fill out this form at a later time. To find the Save and Continue link - Scroll to the bottom of the form. Child's name* First Last Child's date of birth* MM DD YYYY Name of mother/parent bringing child* First Last Phone - mother/parent*Email - mother/parent* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of father/other parent First Last Phone - father/other parentIf child's other parent wants to be in the communication loop, provide contact information.Email - father/parent Child's siblingsNameAgeBirthday Main reason(s) for visit*Check all that apply. In later questions you will be able to more fully describe your concerns. Well child check Breastfeeding Follow-up to tongue tie or lip tie procedures Colic Recovery from traumatic birth Uneven movement of child's head, arms, or legs Uneven head shape, eyes, ears or facial features Clogged ear ducts or ear infections Unusual developmental movements in first year Questions on child development, including developmental milestones Behavior concerns Other Other concernsYou will be able to fill in history later in the form and add notes specific to your pregnancy, birth and newborn days.Please indicate whether this is your child's first visit with Catherine, or if she has seen your child before.*My child will have his/her first session with Catherine now.My child has seen Catherine before.My child's age at the time of this visit is:*If your child was premature, check both birth age and adjusted age, along with the box for prematurity. 0 to 7 days old 8 days to 6 weeks old 7 weeks to 6 months old 7 months to 12 months old 13 months to 24 months old 2 years to 5 years old 6 years to 12 years old Premature, adjusted age indicated. This child was:* Born to me Blended family Adopted Surrogate At what age did your child come into your care?Please describe the transition for your child as he or she came into your careHave you filled out prenatal information during your pregnancy with this child on MamaBebe intake forms previously?*NoYesYes, but I experienced late pregnancy complications that are not recorded on my original intake form for MamaBebe.Please indicate what information is already on file with MamaBebe, if any.This section is to help me understand if I need to gather more information from you. If you have come to see Catherine before, you would be able to skip some questions that you have already filled out.Have you filled out birth & newborn information for this child on MamaBebe intake forms previously?*NoYesYes, and I'd like to update that informationHave you filled out nutrition information for this child on MamaBebe intake forms?*NoYesYes, and I'd like to update that information.Have you filled out your child's health history on MamaBebe intake forms?*NoYesYes, and I'd like to update that information.Have you filled out your child's healthcare provider information on MamaBebe intake forms?NoYesYes, and I'd like to update that information.Conception & preconceptionAge of mother/childbearing person at conceptionDid the mother/childbearing person have any health issues in the year prior to conception? Diabetes High blood pressure Chronic fatigue Gut / digestive problems Yeast Infection Auto immune disorder Other Please describe other maternal health issues prior to conceptionPlease check any conditions relevant to conception: Difficulties conceiving Fertilization assistance History of trauma / abuse Support system of mother/childbearing personMother's response to pregnancy was: Welcoming Mixed feelings Unwelcoming Additional notes on mother's response, optional Father/partner response to pregnancy was: Welcoming Mixed feelings Indifferent or distant Unwelcoming Single parenting, no partner Additional notes on father/partner's response, optional Extended family response to pregnancy & birth was: Welcoming Mixed responses Indifferent or distant Unwelcoming No extended family Other Optional notes on extended family's response Close friends' response to pregnancy & birth was: Welcoming Mixed responses Indifferent or distant Unwelcoming No close friends who influenced pregnancy & birth Other If your baby came to you through a blended family, surrogate or adopted, please note any other known circumstances of your child’s conception, fetal life and birth.Any additional information about the child's surrogacy or adoption?Note briefly any other conditions that you feel are related to your concerns.Prenatal experienceBaby Singleton Multiple How many babies in multiple pregnancy?Baby’s health during pregnancyCheck all that apply. Separate questions about the health of mother/pregnant person will follow. Baby was healthy and well throughout the pregnancy Baby had health issues or risks during pregnancy Infrequent movement Placental insufficiency In utero growth retardation Placenta previa Risk of prematurity Down syndrome or other genetic differences Other Baby 2 -Health during pregnancyCheck all that apply Baby was healthy and well throughout the pregnancy Baby had health issues or risks during pregnancy Infrequent movement Placental insufficiency In utero growth retardation Placenta previa Risk of prematurity Down syndrome or other genetic differences Other Baby 3 -Health during pregnancy Baby was healthy and well throughout the pregnancy Baby had health issues or risks during pregnancy Infrequent movement Placental insufficiency In utero growth retardation Placenta previa Risk of prematurity Down syndrome or other genetic differences Other Describe health concerns further, if you wish:At what gestational week did risks to baby's health become known?Mother/childbearing person's health experience in pregnancyPlease check all that apply. I was healthy and comfortable for the whole pregnancy Persistent discomfort or pain Nausea, reflux or vomiting Severe viral infection 12-25 weeks Severe viral infection 26-36 weeks Allergies Vaginal yeast infection during pregnancy Risk of miscarriage Severe stress Trauma Gestational diabetes Group B strep High blood pressure / hypertension Pre-eclampsia Bleeding during pregnancy Premature contractions Hospitalization Bed rest Accident / Injury Other health complications that may have affected baby Where did you experience persistent pain or discomfort? Lower back Belly Hips Sciatic pain (in buttocks and/or down your leg) Groin - in front hips & upper legs Sides of ribs Shoulders Neck Headache Other pain Describe other persistent pain or discomfort:How much nausea, reflux or vomiting did you experience? Infrequent Mild / Moderate / Manageable Severe When did you experience nausea, reflux or vomiting?Types of allergies Food allergies or sensitivities Seasonal respiratory Animals & dust mites Responses to medication Other allergy Describe food groups to which you are allergic or sensitiveNumber of weeks of miscarriage riskBleeding during the pregnancy was infrequent or mild required bed rest At what gestational week did bedrest begin?Number of weeks on bed restPlease describe why you were hospitalized, including gestational week(s).When did the hospitalization end? Birth During pregnancy Add any other notes on health issues or risks for baby(ies) during pregnancyBriefly describe any other illness you had during pregnancy & when during your pregnancy it occurred.Did health condition(s) of your baby or yourself change how you took care of yourself during pregnancy and/or birth? Yes No Please describe briefly how health condition(s) changed how you took care of yourself during pregnancy and/or birth.Fill in any additional notes which have not been covered in previous questions. Include gestational week or the general time frame of when you changed your self care.Did health conditions for your baby or yourself change how your medical care providers managed pregnancy and/or birth? Yes No Please describe briefly how health condition(s) changed how your medical care providers managed your care during pregnancy and/or birth.Fill in any additional notes which have not been covered in previous questions. Include gestational week or the general time frame of when medical care & management changed.Nutrition & diet during pregnancyPlease give a brief, general description of food that you ate typically.Mother's mind-body health & well-beingMind-body health Usually happy and able to find my emotional balance Often anxious / stressed Often depressed Describe any major events or stressors in your close family, such as death, traumatic accident, job loss during your pregnancy or while caring for your child(ren):Have you experienced the loss of a child in pregnancy, birth, infancy or childhood?NoYesPrior losses in pregnancy, birth or infancyDate of lossAge of childNote if: Miscarriage, lost in childbirth, not carried to term?Brief note on conditions of loss Any additional notes you wish to make about conditions which led to the loss of your childOptional to respondHow has the experience of losing a child affected you?Have you ever experienced rape or sexual assault?NoYesNot sureAny notes on how the experience of sexual assault or rape affected your pregnancy and/or birth for this childOptional to respondMother/Childbearing person's self-care during pregnancyMovement for pregnancy/birth preparation Yoga Walking Swimming Spinning Babies Other movement designed as prenatal activity Other movement for sport & pleasure Other movement detailsAverage amount of time per day for movementMindfulness & mind training practicesCheck any that apply Mindfulness based stress reduction Meditation Somatic practices - mindfulness in movement HypnoBabies HypnoBirth Other mind training practices (add details below) Somatic & other mind training practicesIntegrative therapiesCheck any that apply. Myofascial unwinding or release Craniosacral therapy Chiropractic Massage Acupuncture Other integrative therapy (add details below) Add details for other integrative therapiesChildbirth education classes Hospital based class Childbirth Collective - Parent Topic Nights Independent education (add details below) Independent childbirth education: Class title & instructorYour birthLength of pregnancyNote gestational weeks & daysBaby's birth weightAt birth, how was your baby's health? Baby was healthy & thriving at birth Concerns about breathing Concerns about muscle tone - movement Concerns about vocalizations Concerns about heart rate Concerns about color Although there were initial concerns, baby was fine within 5 minutes. Other concerns Any additional notes on special concerns for the baby at birth.Who, as medical care providers, attended your birth?Check all that apply CNM Midwife Home birth midwife Midwives at freestanding birth center Family practice doctor Obstetrician My baby was born very fast without medical care providers We chose to have a home birth unattended by medical providers. Did a doula attend your birth? Yes No Planned to have a doula, but she did not make it to the birth. Note family members and close friends who attended your birth Husband Partner Wife My mother Other close family member Close friend Other Planned location of birthActual location of birthLength of birth overallHow did your birth begin? began on its own needed some encouragement was induced with natural methods was induced with help of acupuncture was induced with help of herbs was induced with help of foley catheter was induced with medications How did you know that birth had begun on its own? Lost mucus plug Leaking or gushing of water (rupture of membranes) Pressure waves (contractions) began & steadily increased Which home methods did you try to encourage the beginning of birth? Nipple stimulation Lovemaking Walking Spinning Babies activities Movement & positioning Other Which integrative therapies and/or medical methods were tried to induce the beginning of birth? Myofascial release bodywork Chiropractic Acupuncture Herbs Homeopathy Castor oil Cervix ripened with prostaglandins (cervidal) Artificial rupture of membranes (breaking water) Foley bulb Pitocin drip to begin labor Add any other notes about beginning of birthDuring birth process Slow & steady birth Very fast birth Prolonged birth Pressure waves (contractions) steadily increased over time Pressure waves (contractions) remained the same for long periods Pressure waves (contractions) stopped & started with no consistent pattern of increasing intensity Pressure waves (contractions) stopped Cervix opened slowly & steadily Cervix opened rapidly Cervix changed when amniotic sac broke & water came out Cervix changed with position changes & movement Cervix stayed at same dilation for a long time We did not do cervical checks, but tracked movement of baby descending. Amniotic sac had leaking or gushing of water Very intense pressure waves (contractions) Amniotic sac remained intact until baby was born Baby was born in amniotic sac Artificial rupture of membranes (staff broke water sac) Medications to slow down labor Medications to sleep Maternal exhaustion Uterine exhaustion Pitocin augmentation How did pitocin augmentation affect the intensity of your contractions?How did pitocin augmentation affect the progress of your birth?Baby during labor and coming outYou will be able to note newborn conditions in another question. Baby was healthy through labor & birth Baby was well positioned through labor and at birth Baby was in a position that made it difficult for him/her to come through the pelvis. Intermittent fetal monitoring Continuous fetal monitoring, able to be mobile Continuous fetal monitoring, confined to bed Baby large for mother’s pelvis Baby remained high or in the middle for long parts of the birth. Baby stuck as s/he came out Cord wrapped around neck Vacuum extraction Forceps Fetal distress How did you manage the intensity of birth waves or pain? My own images and vision of birth Movement, positions & vocalizing Spinning Babies Focus on sensations of baby moving down Water during labor Waterbirth - while pushing baby out Meditation Presence of loved one Doula support HypnoBabies HypnoBirth Pharmaceutic pain management-> local cervical pain block Pharmaceutic pain management-> sedatives or tranquilizers Pharmaceutic pain management-> nitrous oxide Pharmaceutic pain management-> narcotic Pharmaceutic pain management-> epidural Pharmaceutic pain management-> spinal block Pharmaceutic pain management-> general anesthesia (C-sec) Pharmaceutic pain management-> local vaginal pain block (for stitches or episiotomy) Pharmaceutic pain management-> other (add details below) Other supports (aromas, massage, etc - add details below) Complications & procedures at final stages of birth No complications or interventions at the end of final stages of birth Perineum tear 1st degree Perineum tear 2nd degree Perineum tear 3rd degree Perineum tear 4th degree Perineum cut (episiotomy) 1st degree Perineum cut (episiotomy) 2nd degree Perineum cut (episiotomy) 3rd degree Perineum cut (episiotomy) 4th degree Difficulty delivering placenta Manual delivery of placenta Hemorrhaging (excessive bleeding) Planned caesarean section surgery Emergency caesarean section surgery Infection -> Mom Infection -> Baby Which activities or support were the most helpful for you? Who was the most helpful, and how?Add brief note for other pharmaceutical pain managementAdd brief note for other supports (aromas, massage, etc.)Other major events, or medications & interventions used, if any:Please indicate your feelings about this birthYou can choose from this list, describe in writing below, or both. Check any that apply. Joyful, calm, satisfied. I was able to create the birth I envisioned. My birth went well enough, and I am OK about it. Although we had unexpected turns of events, I am satisfied that we made the best decisions possible at the time and drew upon all the resources available to us. I feel numb about the whole experience. Things happened at my birth which bother me, and it’s still hard to think about or talk about. Traumatic birth, very disturbing. I feel like I am breaking down and unable to get past it. Traumatic birth, I still have a lot of physical pain. Traumatic birth, continues to affect my ability to urinate or pass bowel movements. Traumatic birth has affected my relationships with my partner sexually. Traumatic birth has affected my relationships with my partner sexually. Traumatic birth has affected my relationships with my partner emotionally. If you wish, write your feelings about this birth:If your baby was born from a surrogate or was adopted, please note any other known circumstances of your child’s birth experience.NewbornPlease check any items that applied to your child at birth and as a newborn: My baby was skin to skin with me continuously from birth for at least 2 hours. Separation from you - in room for initial procedures Separation from you - in next room for initial procedures. Separation from you - baby transferred to NICU Delayed first breath Required resuscitation Other difficulty breathing Required incubation (warmer) Choking Swallowed meconium Blue at birth Red (not pink) at birth Heavy bruising (indicate where below) Forceps marks (indicate where below) Jaundice (indicate how long below) Crying excessively Antibiotics given to baby Uneven eye size or placement Uneven ears Misshapen head after 2nd day Sleeping excessively Lethargic / limp Circumcision Surgery Vitamin K Eye ointment Other medications (please describe below) Genetic conditions (please describe below) How long was the separation from you in room for initial procedures?How long was the separation from you when the baby went to NICU?Did baby's father/other parent go with your baby while s/he was separated from you?Describe your baby's stay in the NICUWhere was heavy bruising?Where were forceps marks?How long did jaundice last?Which other medications?Please describe genetic conditions:Anything else that you want me to know about your newborn's experience.If your baby was born from a surrogate or was adopted, please note any other known circumstances of your child’s newborn experience.Child's nutritionAre you and your baby breastfeeding?*You may have done it all! Check whatever applies. Yes, we are breastfeeding exclusively We are breastfeeding, but have difficulties Pumping to feed and/or supplement with my breastmilk Trying, but baby not feeding at breast Supplementing with donor milk Supplementing with formula Not currently breastfeeding or pumping I have decided to not breastfeed, and do not need support for breastfeeding. How has breastfeeding been for you and your baby? Baby and I were able to easily start and maintain breastfeeding Difficulties with latching on Nipple pain or breast pain Tongue tie or lip tie concerns Problems with sucking Concern about inadequate milk production Poor weight gain Delay in milk coming in (past day 5) Delayed in starting breastfeeding due to C-section Delayed in starting breastfeeding due to health conditions for mom Delayed in starting breastfeeding due to health conditions for baby Delayed in starting breastfeeding due to baby was in NICU Delayed in starting breastfeeding due to too many visitors, not enough sleep, and/or not enough helpers Plugged ducts or engorgement Mastitis Sensitivities or allergic reactions to mother's diet Sensitivities or allergic reactions to formula Gassy Persistent spitting up Projectile vomiting Thrush Other If you have had difficulties with breastfeeding, has your child been evaluated for tongue tie or lip tie? Assessed by lactation counselor or consultant Diagnosed by a medical provider or pediatric dentist Assessment or medical evaluation concluded that my baby did not have tongue tie or lip tie My baby was diagnosed with tongue tie and/or lip tie. My baby has had a procedure to clip or laser tongue tie and/or lip tie. We are seeking craniosacral therapy and orofacial therapy during recover from tongue tie and/or lip tie procedure. We want to try gentle integrative therapies before deciding whether to have our child undergo a clip or laser procedure. Other Any additional notes about tongue tie or lip tie:MilkPlease note if your child has received any of the following: Breast milk Formula Cow’s milk Goat’s milk Soy milk Is your child eating solid foods? Yes No Solid foods Vegetables Fruit Grains (note any restrictions below) Beans & peanut butter & nuts (note any restrictions below) Meat Vegetarian or Vegan (note protein sources below) Snacks (note types below) Water Fruit juices Other beverages (note types below) Note any restrictions on grainsNote any restrictions on beans, seeds, nuts or peanutsVegetarian/vegan - Sources of proteinsTypes of snacksTypes of other beveragesMaternal nutrition while breastfeeding:Please describe your current diet.Mother/breastfeeding parent's diet includes Protein Whole grains Dairy Beans Nuts Vegetables Fruit Healthy unrefined oils (olive oil, coconut, etc) Water Omega 3 oils Protein sources include: Vegetarian protein combinations of whole grains, bean & nuts Dairy Eggs Fish Chicken & fowl Pork, beef & other animal sources Other Coffee & caffeine drinks Soft drinks Sugar treats Alcohol Nicotine & tobacco Recreational drugs Describe typical daily sources and amounts of tobacco/nicotinePlease indicate type & amount /frequency.Child's health historyIf this is a follow-up visit, you may update or skip any questions which you have answered in a prior form.Infant health & developmentPlease check any events that applied during infancy: Colic Inconsolable crying Persistent cradle cap Persistent rashes Very smelly stools Constipation or difficult bowel movements Poor eye contact Does not like to be held Arches back frequently Rigid back, legs or arms Turns or tilts head to one side only Startles frequently or persistently Dislikes (or disliked) being placed on tummy Delayed or skipped rolling Delayed in coming to sit on their own Delayed or skipped crawling on belly Delayed or skipped crawling on hands and knees Unusual crawling (one legged; on feet and hands, scooted on bottom, etc.) Adverse reaction(s) to any vaccination within 1-7 days following shots Illness involving a high fever, delirium or convulsions in the first 18 months Add anything else about infant health & development that is related to your concerns.Health conditions and treatmentsPlease list any illnesses or previously diagnosed conditions that your child has experienced, along with his/her general age. Also note medications or treatments to address these.AgeIllnessMedication / Treatment Toxic exposuresNote exposures to environmental toxins during pre-conception period, pregnancy, early childhood and current settings. Note exposures in home, school, outdoor settings and other locations. Include exposures to molds, chlorine bleach, pesticides, herbicides, drugs.AgeExposureMedication / Treatment VaccinationsPlease list any vaccinations and supplemental shots that your child has received. Note adverse reactions, if any, to any vaccination in 1-7 days following shots, such as: Fever Red swollen site of shot Screaming Excessive sleep or inability to sleep Extreme passivity or agitation DateVaccineAdverse reactions, if any Family medical historyIf this is a follow-up visit, you may update or skip any questions which you have answered in a prior form. These relationships are from your child's perspective. M = Mother MGM = Maternal Grandmother PGM = Paternal Grandmother F = Father MGF = Maternal Grandfather PGF = Paternal Grandfather S = Sibling Please use the above codes to note if any blood relatives of your child have had any of the following diseases or conditions: Allergy, asthma or eczemaAttention deficit hyperactivity disorder or variationsCandida, thrush, cradle cap or other yeast infectionFood allergies or sensitivitiesVaccine reactionDevelopmental delay or disabilityScoliosisOther health condition:Child's healthcare providersIf this is a follow-up visit, you may update or skip any questions which you have answered in a prior form.Pediatrician First Last Date of last visit: Pediatrician Date Format: MM slash DD slash YYYY Chiropractor or Osteopath First Last Date of last visit: Chiropractor or Osteopath Date Format: MM slash DD slash YYYY Naturopath First Last Date of last visit: Naturopath Date Format: MM slash DD slash YYYY Craniosacral Therapist First Last Date of last visit: Craniosacral Therapist Date Format: MM slash DD slash YYYY Homeopath First Last Date of last visit: Homeopath Date Format: MM slash DD slash YYYY Herbalist First Last Date of last visit: Herbalist Date Format: MM slash DD slash YYYY Chinese Medicine Practitioner First Last Date of last visit: Chinese Medicine Practitioner Date Format: MM slash DD slash YYYY Occupational Therapist First Last Date of last visit: Occupational Therapist Date Format: MM slash DD slash YYYY Physical Therapist First Last Date of last visit: Physical Therapist Date Format: MM slash DD slash YYYY Other Practitioner First Last Other Practitioner: TitleDate of last visit: Other Practitioner Date Format: MM slash DD slash YYYY How did you learn about MamaBebe services?*Check all that apply Prior visit for myself or one of my children Met Catherine at an event Picked up a card for MamaBebe Referred by my midwife Referred by my doula Referred by my lactation counselor or lactation consultant Referred by my nurse Referred by my childbirth educator Referred by an online forum Referred by a friend Referred by a family member Google search or SEO search Facebook Instagram Met Catherine at:Picked up a card for MamaBebe at:I received a referral from this person or groupI received a referral from this person or groupCheck any that applyBy my signature below, I affirm that I have read & understand the Parent/Guardian Agreement.* I agree to the mutual terms of giving and receiving services in the Parent/Guardian Client Agreement By my signature below, I affirm that I have read & understand the Integrative Therapies Client Bill of Rights.* I have received and understand the Integrative Therapies Client Bill of Rights which includes client rights, full credentials for practitioner Catherine Burns and policies of her practice. Signature*Date* Date Format: MM slash DD slash YYYY CAPTCHAThank you for filling out the Child Intake Form!Thanks so much. You have completed your child's intake form! When you click submit, you will receive a copy of your responses by e-mail. PhoneThis field is for validation purposes and should be left unchanged.
