Postpartum Health Intake Form Your Name * First Name Last Name DOB MM DD YYYY Email * Address Do you have any diseases, conditions, or health complications? (Past or present) Do you currently have any health-related concerns or experience any specific symptoms? If so, are you seeing a holistic or medical practitioner for this? How many children do you have and what are their ages? Were they born vaginally or by cesarean section? Are you currently breastfeeding? If so, exclusively or supplemented? If you no longer breastfeed, how long did you breastfeed for and when did you wean? Are there any food groups or individual foods that you avoid for any reason? (Personal preference or health related) Do you follow any particular diet? (Such as vegan, vegetarian, paleo) Is there anything you would like to change about your diet? Do you experience any specific food cravings? Do you have any food allergies? Do you have any suspected food sensitivities? Are you at a healthy and desired weight, or do you wish to lose/gain weight? If so, how much? What is your past history of antibiotic use? List any nutritional supplements you take and what you take them for (Vitamin, mineral, herbal, homeopathic, etc.): List any medications/prescription drugs and what you take them for: Please click the check boxes that apply. Exercise Daily Weekly Monthly Never Drink 8+ glasses of water per day Daily Weekly Monthly Never Drink coffee Daily Weekly Monthly Never Drink soda (diet or regular) Daily Weekly Monthly Never Drink alcohol Daily Weekly Monthly Never How is your quality of sleep? (1 = poor, 5 = excellent) 1 2 3 4 5 What are your stress levels like? (1 = low stress, 5 = high stress) 1 2 3 4 5 What was your most recent birth experience like? (1 = traumatic, 5 = empowering) 1 2 3 4 5 What are your desired health goals? (Please be specific) Is there anything else to share about your health status? (Please be as thorough as possible) Are there any specific questions or concerns you would like addressed? Thank you for contacting Whole Baby. I will be in contact as soon as possible.
