Postpartum Care

INTAKE FORM

First name

Last name

Birthday

Month

Day

Year

Email Address

Phone

Address

The offering I'm interested in is:

General Herbal Care

Ancestral-based Herbal Care

Birthkeeping

Wellness Questions

What would you like to achieve or change in terms of your health and wellness? (write n/a if not relevant)

What do already do to encourage your wellness and self-care goals? (write n/a if not relevant)

Do you currently engage in any exercise or physical activity? If so, what type(s)?

Please tell us your present concerns and/or conditions. How long have they troubled you?(write n/a if not relevant)

Please list any other personal illnesses, surgeries, injuries, trauma, emotional stresses, mental stresses, life-style conditions, addictions, alcohol, drug abuse, changes of weight, known allergies, or anything else to help us clearly understand you.

Have you worked with or used herbs before? If so, describe which herbs, how, and your experience.

Are there any plants that you like or do not like, are drawn to, or enjoy using? (plants includes trees, herbs, flowers, fruits, and/or vegetables)

Birthkeeping Questions

Please check all services you are interested in from the birthkeeper:

Birth

Postpartum

Placenta Tree Planting and/or Tincture

Other

Why are you seeking a birthkeeper or doula?

Date of last menstrual period:

Month

Day

Year

Do you have irregular periods?

Yes

How many weeks are you into your pregnancy?

Number of Pregnancies

Number of Births

Difficult past pregnancies or complications?

Preferred birth setting:

Hospital

Birth Center

Home

Not sure

Expected due date:

Name of Primary Hospital or Medical Facility

Name of PCP or OBGYN

Are there any specific concerns you have about your upcoming birth?

Are there any family members or friends you would like present during the birth or postpartum time? In what capacity?

Are there any cultural or religious practices or traditions you'd like to incorporate into the birth?

Medications

Are you currently taking any medication?

Yes

If so, please list here:

Do you have any medication allergies?

Yes

If so, please list here:

Do you use or do you have history of using tobacco?

Yes

Do you use or do you have history of using marijuana?

Yes

Do you use or do you have history of using cocaine, heroin, or methamphetamine?

Yes

Do you use or do you have history of using LSD, mescaline, MDMA (ecstasy/molly), or any other drug that may promote hallucinations?

Yes

If you answered "yes" to any of the last four questions, describe what you're taking, how often, how much, and how many years.

If needed, use this space to elaborate on your alcohol use and habits.

Signature

Your signature below indicates that you have read, understand, and agree to the following:

I hereby acknowledge and authorize that the information I provide in this consultation and subsequent information accumulated in my health information files may be used in whole or in part as internal data or case study by the contracted birthkeepers of bibi + ni LLC for data collection and/or educational purposes. My personal identification will be carefully protected from disclosure under Health Insurance Portability and Accountability Act (HIPAA) compliance and policy.

By signing, I acknowledge that I understand and agree to all the terms and conditions detailed in the Initial Intake Form.

First Name

Last Name

Today's Date

Signature

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