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Home Learn more About Us Our Community Mission & Vision Testimonials Anti-Racism Statement & Commitments Events Becoming Jewish Resources Videos Media Members Only Rabbi Denise About Rabbi Denise Jewish Doula Rabbinic Services Teaching & Learning Blog Contact

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Jewish Doula

Client Intake Form

This form provides me with the information I need to get to know you, and start our working relationship. Please fill it in to the best of your ability.

Client Name(s) *

Birthing Person's Phone Number *

The best phone number to reach you.

Country

(###)

###

####

Partner's Phone Number (if applicable)

The best phone number to reach you.

Country

(###)

###

####

Check any of the following which are applicable to you.

Trouble sleeping

Sinus condition

Skin condition

Past surgeries

Frequent Headaches

Severe Headaches

Arthritic Condition

Past Serious Illness

Heart Condition

Past Serious Accident

Hypoglycemic

Diabetic

Allergies

Blood Pressure

Asthma

Communicable Disease

Infectious Disease

Osteoporosis

Cancer or any other Serious Medical Condition

Chronic Fatigue

Check if you have (or have had) problems with any of the following.

Endocrine

Immune & Lymphatic

Respiratory

Urinary

Muscular-Skeletal

Nervous

Cardiovascular

Digestive

Reproductive

Other

If you selected "Other," please provide more details.

Is there anything else about your health you would like to disclose?

Occupation

On a scale of 1-10, how is your level of stress at the moment? *

On a scale of 1-10, how would you describe your level of physical activity on a daily basis? *

Compared to before you were pregnant, is this: *

Normal

An increase

A decrease

How many glasses of water are you drinking on a daily basis? *

Since learning you were pregnant, have you practiced healthy pregnancy habits by avoiding (or greatly reducing) your intake of alcohol, tobacco, drugs, and caffeine? Please describe. *

What is your reason for wanting a doula? *

Regarding labour and delivery, please describe your biggest fear. *

I/we hereby acknowledge that the above information is accurate. *

Confirm

Today's Date *

MM

DD

YYYY

Thank you!

©Denise handlarski

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