Women’s 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 down to the bottom of this form. Name First Last Your date of birth MM DD YYYY PhoneEmail 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 Are you currently pregnant or did you have a baby in the last year? I am currently pregnant I gave birth to a baby in the past year No, I have concerns related to a prior pregnancy or birth No, I want to prepare for pregnancy Not childbearing these days MamaBebe services that I am seeking are: Prenatal somatic bodywork Post-partum bodywork for recovery & support Spinning Babies Parent class (3 hr class) Savvy Birth - Evidence Based class (3 hr class) Somatic Birth prenatal education course (9 weeks) Birth doula & somatic bodywork package I would like support for:Check any that apply Relief from discomfort Open pelvic space for baby to rotate into better position Prepare for birth with alignment activities Know what movements my partner & I can do for an easier birth Connect with my baby in utero Evidence based information for birth planning & decision making. Emotional support through somatic practices Recover from difficult birth Somatic awareness & mindfulness of body Other My main reasons for taking the Spinning Babies Parent class:Add any additional notes, options Estimated guess date of baby's birth MM DD YYYY Date of baby's birth MM DD YYYY Do you have a partner or primary support person for your pregnancy, birth and/or parenting?Please note only the individual(s) who provide you with close emotional support and who will be present at your birth and/or will co-parent with you. Husband Wife Partner Close friend Family member Single parenting by choice Single parenting without partner Name - Husband First Last Name - Wife First Last Name - Partner First Last Name - Close friend or family member First Last Phone - HusbandPhone - WifePhone - PartnerPhone - Close friend or family memberEmail - Husband Email - Wife Email - Partner Email - Close friend or family member Do you identify your gender as being a woman?Some persons who are pregnant & birthing babies do not have a gender identity of being female. My intention is to respect each person's gender identity as chosen by the individual. YesNoMy gender identify can be described as: Trans Queer Other or further description Describe your gender identity: Do you have preferred pronouns? He/him She/her Per/pers They/them Other Other pronouns that you prefer: Does your partner have preferred pronouns? He/him She/her Per/pers They/them Other Other pronouns that your partner prefers: Is this your first session or class with Catherine?Yes, this is my first session or class with Catherine.I have seen Catherine before for bodywork or in a class.Please indicate what information you have already provided on MamaBebe intake forms, if any.Have you filled out information for this pregnancy previously?NoYesYes, but I experienced late pregnancy complications that are not recorded on my original intake form for MamaBebe.Have you filled out information for your birth previously?NoYesYes, and I'd like to update that informationHave you filled out information about your postpartum experience previously?NoYesYes, and I'd like to update that information.Have you filled out nutrition information previously?NoYesYes, and I'd like to update that information.Have you filled out your health history previously?NoYesYes, and I'd like to update that information.Have you filled out you healthcare provider information previously?NoYesYes, and I'd like to update that information.Conception & preconceptionYour age at time of conceptionDid you 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 health issues prior to conceptionPlease check any areas relevant to conception: Difficulties conceiving Fertilization assistance History of trauma / abuse Do you have other children?Check all that apply Yes, I have older children who were born to me Yes, we have a blended family Yes, I have adopted children No Other childrenNameAgeBirthday Your support systemYour response to pregnancy: Welcoming Mixed feelings Unwelcoming Additional notes on your response, optional Father/partner response to pregnancy: Welcoming Mixed feelings Unwelcoming Single parenting, no partner Notes on father/partner's response to pregnancy, optionalExtended family response to pregnancy: Welcoming Mixed responses Unwelcoming No extended family Other Additional notes on extended family's response, optional Close friends' response to pregnancy: Welcoming Mixed responses Unwelcoming No close friends who influence me Other Your prenatal experienceBaby Singleton Multiple How many babies in multiple pregnancy?Describe the position of each baby, if over 28 weeksPosition my baby is in - 28 weeks onBabies can move around in any position up until 28 weeks. From 28 weeks on, it's recommended to help baby to be head down. Check any that apply if baby is 28 weeks or older. My baby is 28 weeks or older. My baby is head down My baby is lying sidewise (transverse breech) My baby's head is at the top (breech) Position my baby is in - direction of facingBabies can move around in any position up until 28 weeks. From 28 weeks on, it's recommended to help baby to be head down, in one of the OA positions (described below). Check any that apply if baby is 28 weeks or older. Baby's head is on my left side, facing back (LOA) Baby's head is in the middle, facing back. (OA) Baby's head is on my right side, facing back. (ROA) Baby's head is in the front, moving side to side. Baby's head is in the front, but the exact position is unknown. Baby's head is on my left side, facing forward. (LOP) Baby's head is in the back & central, facing forward (OP) Baby's head is on my right side, facing forward. (ROP) Baby's head is in the back, but the exact position is unknown. Baby's head is down, but moves around so much that we don't know where s/he is landing. Baby's head is down, but the exact position is unknown. Baby’s health during pregnancyCheck all that apply for baby. Separate questions about your health will follow. Baby - healthy and well throughout the pregnancy Baby - 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 - healthy and well throughout the pregnancy Baby - 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 pregnancyCheck all that apply Baby - healthy and well throughout the pregnancy Baby - 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 At what gestational week did risks to baby's health become known?Describe health concerns further, if you wishMy baby's health condition changed our care plan. I changed how I cared for myself. Our medical team changed how they managed our care. Onset of condition was rapid, with little time to change our plans. Your health experience in pregnancyPlease check all that apply. I have been/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 do/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 do/did you experience? Infrequent Mild / Moderate / Manageable Severe When do/did you experience nausea, reflux or vomiting?Note gestational weeksTypes of allergies Food Seasonal respiratory Animals & dust mites Responses to medication Other allergy Describe other allergiesNumber of weeks of miscarriage riskAdd details about premature contractions, including gestational week(s).Bleeding during the pregnancy was infrequent or mild required bed rest Add details about bleeding, including gestational week(s).Add details about any accidents or injuries, including gestational week(s).Briefly describe any other illness you had/have had during pregnancy, including gestational weeks.Add details about other complications, including gestational week(s).Add any other notes about your health during pregnancy.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? During pregnancy Birth Did health conditions for you or your baby change your care of yourself during your pregnancy and/or your birth in any other ways? Yes No Please describe briefly how health condition(s) changed your 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 you or your baby change how your medical care providers managed your pregnancy and/or your 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.What is your height?So I can have big balls of the proper size for you.Nutrition & Diet during PregnancyPlease give a brief, general description of food that you ate typically.Your nutrition & diet during pregnancyDay to day diet includes/included: Protein Whole grains Dairy Beans Nuts Vegetables Fruit Healthy unrefined oils (olive oil, coconut, etc) Vitamin & mineral supplements Omega 3 oils Water Protein sources include: Vegetarian protein combinations of whole grain, beans & nuts Dairy Eggs Fish Chicken & fowl Pork, beef and other animal sources Other Coffee & caffeine drinks Soft drinks Sugar - Cookies, desserts, candy Alcohol Nicotine & tobacco Recreational drugs Tobacco & nicotinePlease indicate type & amount / frequency.AlcoholPlease indicate type & amount / frequency.Recreational DrugsPlease indicate type & amount / frequency.Your mind- body health & well-beingMind-body health Often happy Often anxious / stressed Often depressed Describe any major events or stressors in your close family, such as death, traumatic accident, job loss during pregnancy and/or postpartum.Were there concerns from prior miscarriage, infant loss or decision to not carry a pregnancy to term? If so, please describe.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 experienced rape or sexual assault?NoYesNot sureAny notes on how the experience of sexual assault or rape affects/affected your pregnancy and/or birth.Optional to respondYour 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 practices Mindfulness based stress reduction Meditation Somatic practices - mindfulness in movement HypnoBabies HypnoBirth Other mind training practices (add details below) Somatic & other mind training practicesIntegrative therapies Myofascial unwinding or gentle 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 providers, attended your birth?Check all that apply CNM midwife Home birth midwife Midwives at freestanding birth center Family practice doctor Obstetrician We chose to have a home birth unattended by medical providers. My baby was born very fast without medical care providers Other Did you have a doula attend your birth?Check all that apply Yes No Planned to have a doula, but she did not make it to the birth Did your doula provide you with assistance after the birth?Make any notes you wish.Note types of integrative therapists who attended your birthNote family members and close friends who attended your birthCheck all that apply Husband Wife Partner 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 aid 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 Very intense pressure waves (contractions) Cervix opened slowly & steadily Cervix open rapidly Cervix stayed at same dilation for a long time Cervix changed when amniotic sac broke & water came out Cervix changed with position changes & movement We did not do cervical checks, but tracked movement of baby descending. Amniotic sac had leaking or gushing of water Amniotic sac remained intact until baby was born Baby was born in amniotic sac Artificial rupture of membranes (staff broke water bag) 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 out Baby was healthy through labor & birth Baby was well positioned through labor & 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 for long parts of the birth. Baby remained in the middle of the birth canal for a long time. Cervix Baby stuck as s/he came out Cord wrapped around neck Vacuum extraction Forceps Fetal distress Complications & procedures at final stages of birth No complications or interventions at the end of the 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) 4rd Degree Difficulty delivering placenta Manual delivery of placenta Hemorrhaging (excessive bleeding) Planned caesarean section surgery Emergency caesarean section surgery Infection -> Mom Infection -> Baby 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 Partner support Doula support HypnoBabies HypnoBirth TENS unit - Transcutaneous Electrical Nerve Stimulation 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) Which activities or support were the most helpful for you? Who was the most helpful to you, in what ways?Add brief note for other pharmaceutic 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. 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 emotionally. Traumatic birth has affected my relationships with my partner sexually. If you wish, write your feelings about this birth:Your 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 went 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 Forceps marks Jaundice 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?Please describe genetic conditions:Anything else that you want me to know about your newborn's experience.BreastfeedingAre you breastfeeding or did you ever breastfeed?You may have done it all. Check whatever applies We are currently breastfeeding or attempting to breastfeed. Yes, we are breastfeeding exclusively. Yes, we breastfed for the first six months exclusively. We attempted to breastfeed, but have or had much difficulty Pumping to feed and/or supplement with my breastmilk Trying or tried, but baby not feeding at breast Not currently breastfeeding or pumping Supplementing with donor milk Supplementing with formula Feeding exclusively with formula I have decided to not breastfeed. I do not need support for breastfeeding. How do/did you and your baby experience breastfeeding? Baby and I were able to easily start and maintain breastfeeding Difficulties with latching on Nipple 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 Any supplementation?You may have done it all! Check whatever applies. Donor milk supplementation Formula supplementation (with breastfeeding) Formula feeding (without breastfeeding) Anything else that you want me to know about your experiences breastfeedingYour nutrition while breastfeedingHas your nutritional intake changed during breastfeeding? I eat mostly the same type of foods as while pregnant. I have changed my diet to help my postpartum recovery. I have eliminated foods as I think my baby is sensitive to some food groups. Anything else that you want me to know about changes in your food intake.Your postpartum recoveryHow has your postpartum experience been physically? I am recovering/have recovered from birth with no physical complications. I have painful or persistent hemorrhoids I have painful or persistently uncomfortable nipples I have pain from stitiches or tearing. Recovery from C-section has been difficult. Other complications of birth & postpartum recovery. How has your postpartum experience been for your emotional wellbeing? I am recovering/have recovered from birth with no emotional complications. I feel a little low at times. I am often depressed or anxious. I am angry about my birth. I am frustrated about not having support that I need. Other emotional challenges of birth & postpartum recovery. Anything else that you want to share about your postpartum experience.Your health historyIf this is a follow-up visit, you may update or skip any questions which you have answered in a prior form.AccidentsPlease list any accidents that you have experienced, along with your age at the time. Also note general treatments that you did to address these.AccidentParts of the body affectedTreatmentAge Chronic aches & painsPlease list any chronic aches & pains that you have experienced, along with your age at the time they began. Also note general treatments that you have done to address these.Chronic conditionParts of the body affectedTreatmentAge Health conditions and treatmentsPlease list any illnesses or previously diagnosed conditions that you has experienced, along with your age at the time. Also note general treatments that you have done to address these.IllnessMedication / TreatmentAge Family Medical HistoryIf this is a follow-up visit, you may update or skip any questions which you have answered in a prior form. 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 of your blood relatives have had any of the following diseases:Allergy, asthma or eczemaCandida, thrush, cradle cap or other yeast infectionFood allergies or sensitivitiesGestational diabetes or low blood sugarDiabetes (ongoing condition, prior to pregnancy)High blood pressure / strokeMental illnessStrep BOther Health Condition:Your healthcare providersIf this is a follow-up visit, you may update or skip any questions which you have answered in a prior form.Midwife First Last Midwife clinical groupDate of last visit: Midwife Date Format: MM slash DD slash YYYY Doctor First Last Doctor - clinical groupDate of last visit: Doctor 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 groupBy my signature below, I affirm that I have read & understand the Client Agreement.* I agree to the mutual terms of giving and receiving services in the 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 Childbearing Woman Intake Form!Thanks so much. You have completed your intake form! When you click submit, you will receive a copy of your responses by e-mail. NameThis field is for validation purposes and should be left unchanged.
