About this template
Streamline your client onboarding process with this comprehensive New Client Intake and Medical History Google Form template. Designed specifically for birth workers, doulas, and prenatal wellness practitioners, this template captures essential personal details, emergency contacts, partner information, and detailed medical and obstetric histories. It helps you understand each client's unique background, prior birth experiences, current health status, and personal preferences before your initial consultation.
By gathering this detailed information digitally in advance, you can review medical considerations, prepare personalized care plans, and ensure you are fully equipped to support your clients through pregnancy, labor, and postpartum. The structured sections make it easy for clients to share sensitive health details at their own pace while reducing administrative paperwork for your practice.
Key features
- Comprehensive health and medical background tracking
- Detailed obstetric and previous pregnancy history sections
- Emergency contacts and partner information collection
- Personalized birth preferences and support goals
- Fully customizable for virtual or in-person practices
Use cases
- Virtual and in-person doula client onboarding
- Prenatal wellness and childbirth education consultations
- Midwifery and holistic birth care intake
- Postpartum support and care planning
What this form collects
- Client Full Name (Short answer)Enter your first, middle, and last name.
- Client Preferred Name (Short answer)What name would you like us to use when addressing you?
- Client Preferred Gender Pronouns (Short answer)E.g., she/her, they/them, he/him.
- Client Birth Date (Date)Please provide your date of birth.
- Email Address (Short answer)Where can we send appointment confirmations and resources?
- Mobile Phone Number (Short answer)Best number for calls or text messages.
- Street Address (Paragraph)Your current residential address.
- Emergency Contact Full Name (Short answer)Name of someone we can reach in case of an emergency.
- Emergency Contact Phone Number (Short answer)Direct phone number for your emergency contact.
- Emergency Contact Relationship (Short answer)E.g., Spouse, Parent, Friend.
- Allergies and Sensitivities (Paragraph)List any known allergies to medications, foods, latex, or environmental factors, along with your typical reaction.
- Prescription Medications and Doses (Paragraph)List all current prescription medications and their dosages.
- Over-the-Counter Medicines, Herbs, and Supplements (Paragraph)List any regular supplements, vitamins, or herbal remedies you take.
- Medical Condition History (Paragraph)Describe any past or ongoing medical conditions (e.g., gestational diabetes, high blood pressure, asthma).
- Smoking Status (Multiple choice)Select your current smoking habits.
- Planned Birth Location (Dropdown)Where do you currently plan to give birth?
- Hospital or Birth Center Name (Short answer)Provide the name of the facility if applicable.
- Ultrasound Estimated Due Date (Date)Your estimated due date based on your most recent ultrasound or provider calculation.
- Number of Pregnancies (Gravida) (Short answer)Total number of times you have been pregnant, including the current pregnancy.
- Current Pregnancy Symptoms and Concerns (Paragraph)Describe any symptoms, discomforts, or specific concerns you have right now.
- Reason for Seeking Doula Support (Paragraph)What made you decide to seek doula support for this pregnancy?
- Pregnancy, Birth, or Parenting Fears (Paragraph)Share any specific worries or anxieties you hope to work through.
- Infant Feeding Plan (Multiple choice)How do you currently plan to feed your baby?
- Additional Notes or Comments (Paragraph)Anything else you would like us to know before our initial meeting.
FAQ
What is a New Client Intake and Medical History Form?
It is a comprehensive questionnaire used by wellness practitioners, doulas, and birth workers to gather essential background data, health history, and care preferences from new clients before their first official session.
Why should I use a digital intake form instead of paper?
Digital forms allow clients to complete their medical history securely from home, eliminating manual data entry, reducing lost paperwork, and helping you review health backgrounds before appointments.
Can I customize the questions in this template?
Yes! Once you generate this form with Doc2Form, it opens directly in your Google Drive, where you can add, remove, or edit any questions to fit your specific practice guidelines.
What type of information does this form collect?
It covers client contact details, emergency contacts, current medications and allergies, past medical history, detailed obstetric and pregnancy history, and personal birth preferences.
Is this template suitable for telehealth or virtual consultations?
Absolutely. It is designed to bridge the gap for virtual practitioners who need detailed intake records before meeting clients via video call.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.