Medical History Form

This form allows me to get a clear picture of your health and how I can best serve you. Information gathered will only be seen by me and never shared.

Name:

Email Address:

Have you ever had or do you currently have an eating disorder? If so, when?

How have you been eating throughout the pregnancy?

How many hours do you normally sleep at night?

Do you sleep well?

Do you have an opportunity for a rest period or nap throughout the day?

What # pregnancy is this for you?

What # birth is this for you?

Did you experience any fertility issues?

Did you receive any fertility treatments? If yes, what?

In general, how have you felt throughout the pregnancy? Describe any difficulties, challenges, complaints, or perks.

Please list any vitamins/medications that you are taking now:

Do you have any known allergies? If so, what?

Any sensitivities to essential oils or herbs?

Do you have any questions or comments?

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Jodi Guererri LMT

BASED IN GENEVA, NY

jodi@lavendermintdoula.com

SERVICING THE FINGER LAKES & ROCHESTER AREAS OF NEW YORK.