Pregnancy Health Intake Form Your Name * First Name Last Name DOB MM DD YYYY Email * Address How many weeks pregnant are you? Have you given birth before? If so, was it vaginal or cesarean section? Are you receiving prenatal care with a midwife or obstetrician? Have you or are you currently experiencing any pregnancy related conditions, or specific symptoms? Have you or are you currently experiencing any specific cravings? Has your diet changed at all since becoming pregnant? Are there any specific foods or substances that you are avoiding while pregnant? Are there any food groups or individual foods that you avoid for any reason? (Personal preference or health related) Has weight gain or loss been a concern for you or your care providers during this pregnancy? Do you follow any particular diet? (Such as vegan, vegetarian, paleo) Do you have any food allergies? Do you have any suspected food sensitivities? 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 soft drink (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 Is there anything else to share about your health status? 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.
