Child intake MamaBebe is committed to your privacy. We will never sell or give away your information. Many sections of this form are optional, and you may skip them. Please fill out the information that you feel is most relevant. Your child's birth story is important information for all the work that we do together. 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 to the bottom of the form. Child's name* First Last Child's date of birth* Month Day Year Your name* First Last Your phone*Your email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of father/other parent First Last Phone - father/other parentIf child's other parent wants to be in the communication loop, provide contact information.Email - father/parent Child's siblingsNameAgeBirthday Main reason(s) for visit*Check all that apply. In later questions you will be able to more fully describe your concerns. Well child check Breastfeeding Tongue tie or lip tie Colic Recovery from traumatic birth Uneven movement of child's head, arms, or legs Uneven head shape, eyes, ears or facial features Clogged ear ducts Chronic ear infections Unusual developmental movements in first year Questions on child development, including milestones Behavior concerns Other Other concernsYou will be able to fill in history later in the form and add notes specific to your pregnancy, birth and early days.My child's age at the time of this visit is:*If your child was premature, check both birth age and adjusted age, along with the box for prematurity. 0 to 12 days old 12+ days to 6 weeks old 7 weeks to 3 months old 4 to 6 months old 7 to 12 months old 1 to 2 years old 3 to 5 years old 6 to 12 years old 12 years and older Premature, adjusted age indicated. This child:* Was born to me Is a member of our blended family Was adopted Born via surrogate Did you have any complications with conceiving your baby? Yes, difficulty conceiving this child No complications in conception Please note age of mother at time of your child's birth At what age was your child when they came into your care? Please describe the transition for your child as he or she came into your careConception & preconceptionAll questions are optional. Respond to those related to any concerns for your baby.Did the mother/childbearing person 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 maternal health issues prior to conceptionPlease check any conditions relevant to conception: Fertilization assistance History of trauma / abuse Any notes you'd want to make about your conception journeySupport system for motherOptional questions. Please respond if you're not well supported.Mother's response to pregnancy was: Welcoming Mixed feelings Unwelcoming Additional notes on mother's response, optional Father/partner response to pregnancy was: Welcoming Mixed feelings Indifferent or distant Unwelcoming Single parenting, no partner Additional notes on father/partner's response, optional Extended family response to pregnancy & birth was: Welcoming Mixed responses Indifferent or distant Unwelcoming No extended family Other Optional notes on extended family's response Close friends' response to pregnancy & birth was: Welcoming Mixed responses Indifferent or distant Unwelcoming No close friends who influenced pregnancy & birth Other If your baby came to you through a blended family, surrogate or adopted, please note any other known circumstances of your child’s conception, fetal life and birth.Any additional information about the child's surrogacy, adoption or blended family?Note briefly any other conditions that you feel are related to your concerns.Prenatal experienceBaby Singleton Twins Multiple Baby’s health during pregnancyCheck all that apply. Separate questions about the health of mother/pregnant person will follow. Baby was healthy and well throughout the pregnancy Baby had health issues or risks during pregnancy Infrequent movement Baby often in the same position in final trimester I felt kicks in the same area through the final trimester Risk of prematurity Low amniotic fluid Placental insufficiency Placenta previa In utero growth retardation Down syndrome or other genetic differences Other Baby 2 -Health during pregnancyCheck all that apply Baby was healthy and well throughout the pregnancy Baby had health issues or risks during pregnancy Infrequent movement I felt kicks in the same area through the final trimester Risk of prematurity Low amniotic fluid Placental insufficiency Placenta previa In utero growth retardation Down syndrome or other genetic differences Other Baby 3 -Health during pregnancy Baby was healthy and well throughout the pregnancy Baby had health issues or risks during pregnancy Infrequent movement I felt kicks in the same area through the final trimester Risk of prematurity Placental insufficiency Low amniotic fluid Placenta previa In utero growth retardation Down syndrome or other genetic differences Other Describe health concerns further, if you wish:At what gestational week did risks to baby's health become known?Mother's health experience in pregnancyPlease check all that apply. I (the mother) 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 did you experience persistent pain or discomfort? Lower back Belly Vaginal & pelvic floor pressure Hips Sciatic pain (in buttocks and/or down your leg) Groin - in front of hips & upper legs Lower ribs Sides of ribs or torso Shoulders Neck Headache Other pain Describe other persistent pain or discomfort: How much nausea, reflux or vomiting did you experience? Infrequent Mild / Moderate / Manageable Severe When did you experience nausea, reflux or vomiting? Types of allergies Food allergies or sensitivities Seasonal respiratory Chronic respiratory Animals & dust mites Responses to medication Other allergy Describe food groups to which you are allergic or sensitive Number of weeks of miscarriage riskBleeding during the pregnancy was infrequent or mild required bed rest 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 Extended beyond 2 days postpartum Add any other notes on health issues or risks for baby(ies) during pregnancyBriefly describe any other illness you had during pregnancy & when during your pregnancy it occurred.Did health condition(s) of your baby or yourself change how you took care of yourself during pregnancy and/or birth? Yes No Please describe briefly how health condition(s) changed how you took 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 your baby or yourself change how your medical care providers managed pregnancy and/or 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.Nutrition & diet during pregnancyPlease give a brief, general description of food that you ate typically.Mother's mind-body health & well-beingMind-body health Usually happy and able to find my emotional balance Often anxious / stressed Often depressed Describe any major events or stressors in your close family, such as death, traumatic accident, job loss during your pregnancy or while caring for your child(ren):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 ever experienced rape or sexual assault?NoYesNot sureAny notes on how the experience of sexual assault or rape affected your pregnancy, birth and/or parenting for this childOptional to respondBirth of your childPlease be sure to fill out this section, as your child's birth greatly affects many conditions and issues; especially breastfeeding, newborn concerns and child development. If your child was born by surrogate, include as much information as you know. Length of pregnancyNote gestational weeks & days Baby's birth weight At birth, how was your baby's health?In another section, you will be able to describe your baby's conditions following these notes about first moments of their life. 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 your baby at birth.Who, as medical care providers, attended your birth?Check all that apply CNM Midwife Home birth midwife Midwives at freestanding birth center Family practice doctor Obstetrician My baby was born very fast without medical care providers We chose to have a home birth unattended by medical providers. Did a doula attend your birth? Yes No Planned to have a doula, but she did not make it to the birth. Note family members and close friends who attended your birth Husband Wife Partner My mother Other close family member Close friend Other Planned location of birth Actual location of birth Length of birth overall How did your birth begin? began on its own needed some encouragement was induced with natural methods was induced with medical assistance 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 Body Ready Method® activities 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 Other How did pitocin augmentation affect the progress of your birth?How did pitocin augmentation affect the intensity of your contractions?During 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 & started with no consistent pattern of increasing intensity Pressure waves (contractions) stopped Cervix opened slowly & steadily Cervix opened rapidly Cervix changed when amniotic sac broke & water came out Cervix changed with position changes & movement Cervix stayed at same dilation for a long time We did not do cervical checks, but tracked movement of baby descending. Amniotic sac had leaking or gushing of water Very intense pressure waves (contractions) Amniotic sac remained intact until baby was born Baby was born in amniotic sac Artificial rupture of membranes (staff broke water sac) Medications to slow down labor Medications to sleep Maternal exhaustion Uterine exhaustion Pitocin augmentation Add any other notes about beginning of birthBaby during labor and coming outYou will be able to note newborn conditions, right after baby was born, in another question. Baby was healthy through labor & birth Baby was well positioned through labor and at 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 I was told that my baby large for my pelvis Baby remained high or in the middle for long parts of the birth. Baby stuck as s/he came out (shoulder dystocia) Cord wrapped around neck Vacuum extraction Forceps Fetal distress Other How did you manage the intensity of birth waves or pain? My own images and vision of birth Movement, positions & vocalizing Spinning Babies® movements Body Ready Method® movements Focus on sensations of baby moving down Water during labor Waterbirth - while pushing baby out Meditation Presence of loved one Doula support HypnoBabies HypnoBirth 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 Other supports (aromas, massage, etc) Complications & procedures at final stages of birthYou will have a separate question about your newborn's condition following their birth. No complications or interventions at the end of final stages of birth Cord wrap Shoulder dystocia (baby stuck as they came out) 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) 4th degree Difficulty delivering placenta Manual delivery of placenta Hemorrhaging (excessive bleeding) Planned caesarean section surgery Emergency caesarean section surgery Infection -> Mom Infection -> Baby Which activities or support were the most helpful for you? Who was the most helpful, and how?Add brief note for other pharmaceutical 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. Check any that apply. 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, I still have a lot of physical pain. Traumatic birth, continues to affect my ability to urinate. Traumatic birth, continues to affect my ability to pass bowel movements. Traumatic birth, very disturbing. I feel like I am breaking down and unable to get past it. Traumatic birth has affected my relationship with my baby. Traumatic birth has affected my relationship with my partner emotionally. Traumatic birth has affected my relationship with my sexually. If you wish, write your feelings about this birth:If your baby was born from a surrogate, is adopted, or a member of your blended family, please note any other known circumstances of your child’s birth experience.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 transferred 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 Serious medical condition Vitamin K Eye ointment Other medications Genetic conditions How long was your baby separated from you for initial procedures? How long was the separation from you when the baby went to NICU? Did baby's father/other parent go with your baby while s/he was separated from you? Describe your baby's stay in the NICUWhere was heavy bruising? Where were forceps marks? How long did jaundice last? Describe other medications brieflyPlease describe genetic conditions briefly:Anything else that you want me to know about your newborn's experience.If your baby was born from a surrogate, is adopted, or a member of your blended family, please note any other known circumstances of your child’s newborn experience.Child's nutritionAre you and your baby breastfeeding?*You may have done it all! Check whatever applies. Yes, we are breastfeeding exclusively We are breastfeeding, but have difficulties Pumping to feed and/or supplement with my breastmilk Trying, but baby not feeding at breast Supplementing with donor milk Supplementing with formula Breastfeeding & feeding solids Not currently breastfeeding or pumping I have decided to not breastfeed, and don't need support for breastfeeding. How has breastfeeding been for you and your baby?Check any and all that you & your baby have experienced. If you're not sure, bring your questions to session. Baby and I were able to easily start and maintain breastfeeding Difficulties with latching on Problems with sucking Poor weight gain Inconsolable crying Nipple pain or breast pain Nipple trauma - damaged tissue Breast feels bruised Shooting pains in breast Delay in milk coming in (past day 5) Delayed in starting breastfeeding due to C-section Delayed in starting breastfeeding due to medications at birth 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 Concern about inadequate milk production Milk supply started OK, now decreasing Baby was breastfeeding fine to start, but now ithey are not feeding well Plugged ducts Engorgement past initial day when milk came in Inflamed or red, hot areas on breast Mastitis Sensitivities or allergic reactions to mother's diet Sensitivities or allergic reactions to formula Tongue tie or lip tie concerns Clicking sounds during feeding Milk leaking out of side of mouth during feed Milk dribbling milk out of the front of the mouth Seems to be blisters on mouth Two tone lips Top or bottom lip not flanging out during feed Coughing or choking Gagging White tongue Excessive hiccups (frequency & length) Very gassy Vary gassy, often distressing Persistent spitting up Spits up right after a feeding Spits up more than 15 minutes after feeding Projectile vomiting Very slow feedings (over 30 minutes) Falls asleep at breast before feed is completed Has to be woken up for most feeds Very short feeds, then baby has to feed again very soon (less than 1:30 hrs) Excessive jaw movements, opening & closing, during feed Feels like baby is chomping or biting me Cheeks dimple during feed Tongue doesn't reach out past lower gums Thrush Other Have you been concerned that your child may have/has any of these conditions? Reflux Colic Thrush Who has provided you with an assessment or information about reflux, colic or thrush?Check any that apply. My own research & experience Family or friends On-line moms group Lactation counselor, educator or consultant Nurse Has a medical provider provided you with a diagnosis of reflux, colic or thrush?Check any that apply. Pediatric dentist, DDS or DMD Pediatrician, MD or NP Nurse, NP or Physician's Assistant, PA Oral surgeon, MN IBCLC, Internationally Board Certified Lactation Consultant Ear, nose & throat doctor (ENT, otolayrngologist) Are you concerned that your child may have/has tongue tie, lip tie or cheek ties?Check any that apply Select All Tongue tie Lip tie Cheek tie Who has provided you with an assessment or information about tongue, lip or cheek ties?Check any that apply. My own research & experience Family or friends On-line moms group Lactation counselor, educator or consultant Has a medical provider diagnosed your baby as having tongue tie, lip tie or cheek ties?Check any that apply. Pediatric dentist, DDS or DMD Pediatrician, MD or NP Nurse, NP or Physician's Assistant, PA IBCLC, Internationally Board Certified Lactation Consultantt Oral surgeon, MN Ear, nose & throat doctor (ENT, otolayrngologist) Has a revision procedure been considered, scheduled or completed? My baby has had a revision procedure. We are scheduled to have a revision procedure done. We are undecided about doing a revision procedure. We have received varying diagnoses. Any additional notes about tongue tie or lip tie: MilkPlease note if your child has received any of the following: Breast milk Donor milk Formula Cow’s milk Goat’s milk Soy milk Is your child eating solid foods? Yes No Solid foods Vegetables Fruit Grains Beans & peanut butter & nuts Meat Vegetarian or Vegan Snacks Water Fruit juices Other beverages Vegetarian/vegan - Sources of proteins Any brief notes you want to include on your child's diet Maternal nutrition while breastfeeding:Please describe your current diet.Mother/breastfeeding parent's diet includes Select All Protein Whole grains Dairy Beans Nuts Vegetables Fruit Healthy unrefined oils (olive oil, coconut, etc) Water Omega 3 oils Protein sources include: Vegetarian protein combinations of whole grains, bean & nuts Dairy Eggs Fish Chicken & fowl Pork, beef & other animal sources Other Coffee & caffeine drinks Soft drinks Sugar treats Alcohol Nicotine & tobacco Cannabis Recreational drugs Your child's development & healthIf this is a follow-up visit, you may update or skip any questions which you have answered in a prior form.Infant health & developmentPlease check any concerns you may have now or in the past. Poor eye contact Does not like to be held Arches back frequently Rigid back, legs or arms Turns or tilts head to one side only Startles frequently or persistently Dislikes (or disliked) being placed on tummy Delayed or skipped rolling Delayed in coming to sit on their own Delayed or skipped crawling on belly Delayed or skipped crawling on hands and knees Unusual crawling (one legged; on feet and hands, scooted on bottom, etc.) Inconsolable crying Colic Persistent cradle cap Persistent rashes Very smelly stools Constipation or difficult bowel movements Adverse reaction(s) to any vaccination within 1-7 days following shots Illness involving a high fever, delirium or convulsions in the first 18 months Child health & development - early childhoodCheck any additional concerns for your child's behaviors. Biting Pinching Hitting Kicking Head banging Self injury Tantrums Note any other concerns about your baby's development.Note any other concerns about your child's development.Health conditions and treatmentsPlease list any illnesses or previously diagnosed conditions that your child has experienced, along with his/her general age at the time. Please also note medications or treatments to address these conditions.AgeIllnessMedication / Treatment Toxic exposuresNote exposures to environmental toxins during pre-conception period, pregnancy, early childhood and current settings. Note exposures in home, school, outdoor settings and other locations. Include exposures to molds, chlorine bleach, pesticides, herbicides, drugs.AgeExposureMedication / Treatment VaccinationsPlease list any vaccinations that your child has received. Note adverse reactions, if any, to any vaccination in 1-7 days following shots, such as: Fever, Red swollen site of shot, Screaming, Excessive sleep or inability to sleep, or Extreme passivity or agitation, DateVaccineAdverse reactions, if any Allergy, asthma or eczema Candida, thrush, cradle cap or other yeast infection Food allergies or sensitivities Developmental delay or disability Other health conditions:Child's healthcare providersIf this is a follow-up visit, you may update or skip any questions which you have answered in a prior form.Health care practitioners who provide care for your child Pediatrician General medical practitioner (MD, Family doctor) Nurse practitioner or Physician's assistant Lactation consultant Pediatric dentist Naturopath Chiropractor or Osteopath Craniosacral therapist Herbalist Homeopathist Chinese medicine doctor Physical therapist Occupational therapist Medical specialist Other General MD, Family doctor or PediatricianProvider or clinical group Date of last visit: General MD, Family doctor or pediatrician MM slash DD slash YYYY Nurse practitioner or Physician's assistantProvider or clinical group Date of last visit: Nurse practitioner or Physician's assistant MM slash DD slash YYYY Lactation consultantProvider & setting (hospital, clinic, pediatrician, etc) Date of last visit: Lactation support MM slash DD slash YYYY Pediatric dentistProvider or clinical group Date of last visit: Pediatric Dentist MM slash DD slash YYYY NaturopathProvider's name Date of last visit: Naturopath MM slash DD slash YYYY Chiropractor or OsteopathProvider's name Date of last visit: Chiropractor or Osteopath MM slash DD slash YYYY Craniosacral therapistProvider's name Date of last visit: Craniosacral Therapist MM slash DD slash YYYY HerbalistProvider's name Date of last visit: Herbalist MM slash DD slash YYYY HomeopathistProvider's name Date of last visit: Homeopathist MM slash DD slash YYYY Chinese medical practitionerProvider's name Date of last visit: Chinese Medicine Practitioner MM slash DD slash YYYY Physical therapistProvider or clinical group Date of last visit: Physical Therapist MM slash DD slash YYYY Occupational therapistProvider or clinical group Date of last visit: Occupational Therapist MM slash DD slash YYYY Other PractitionerNote provider or clinical group and specialization Date of last visit: Other Practitioner MM slash DD slash YYYY How did you learn about MamaBebe services?*Please check all that apply. Prior visit for myself or one of my children 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 a friend Referred by a family member Referred by an in-person community group Referred by an online forum Instagram Facebook Google or SEO search Well Connected Twin Cities directory Spinning Babies® directory Body Ready Method® directory ISMETA somatic practitioners' directory Met Catherine at an event Picked up a card for MamaBebe I received a referral from this practitioner or groupPlease note provider or clinical groupI received a referral from this community groupI received a referral from this personIf you can share your friend or family member's name:I picked up a card for MamaBebe at: I met Catherine at: By my signature below, I affirm that Catherine may contact me.* I agree that Catherine may text, email or call me about my concerns for my child. I agree that Catherine may email or call me about my concerns for my child and MamaBebe services. By my signature below, I affirm that I have received access to & read the Parent/Guardian Client Agreement.* I agree to the terms of receiving services in the MamaBebe Parent/Guardian Client Agreement By my signature below, I affirm that I have received access to & read the Integrative Therapies Client Bill of Rights.* I agree to the terms of the MamaBebe Integrative Therapies Client Bill of Rights which includes client rights, full credentials for practitioner Catherine Burns and policies of her practice. Signature* Date* MM slash DD slash YYYY CAPTCHAThank you for filling out the Child Intake FormThanks so much. You have completed your child's intake form! After you click submit, you will receive a copy of your responses by e-mail. I look forward to meeting you and your child - Catherine CommentsThis field is for validation purposes and should be left unchanged.
