Intake Form for Mamas

Thank you for your interest in our Mama program. At Kristy Mia, we are dedicated to supporting and empowering women on their journey through motherhood. Please take a few moments to fill out this intake form to help us understand your needs better and provide you with the best support possible.

Date

Name

First Name

Last Name

Complete Address

Phone

Day & Evening

(###)

###

####

Mobile Number

(###)

###

####

Partner's Name

First Name

Last Name

Partner's Email & Mobile #

Birthdate

YYYY

Age / Height & Weight / Blood Type

Ancestry/Ethnicity

Family & Living Situation

Occupation

Allergies

Midwife/Doctor/Care provider

Include phone numbers

Other health care providers/insurance providers

Medical conditions/ procedures during the last 7 years

What is your regular exercise routine and recreational exercise? How often?

What do you do to relax and destress?

Describe the onset and reoccurrence of any health issues in detail:

Have you experienced any health issues during this pregnancy?

How have you dealt with these concerns thus far?

Have any family members had similar problems?

Please describe

List any supplements or medications you are taking and for what purpose for each

Please describe how your birth was in detail, as well as any sibling's birth

Do you have any fears going into this birth? Being a parent?

Tell me how your fears and concerns impact you, your life, family & partner?

Please describe the condition and tendency of your:

Skin Hair Nails

Please list any addictive behaviours

(Past and present use and abuse of alcohol, drugs, tobacco, birth control pills, caffeine, food, codependency, workaholism)

Do you have any injuries? If so, where are they located and how do they affect you?

What are toxins now and past- food and environmental exposure, parasites?

What support are you wanting to receive from me as your Childbirth Educator and Doula?

What is your vision for your birth and most important desires for labor and delivery?

Please list your desired payment schedule with amounts and dates

Consent

By submitting this intake form, you acknowledge that the information provided is accurate and that you consent to participate in our programs.

I Agree