Client Intake Form

Please answer the following:

Full Name: *

Date of Birth: *

Age: *

Contact Number: *

Email Address: *

Emergency Contact Number: *

When was the first day of your last period (LMP): *

Were you given an estimated due date? If so, what is your due date? *

Are your cycles regular? *

Is your current pregnancy spontaneous or through IVF/IUI? *

Including your current pregnancy, how many times have you been pregnant? *

Have you experienced a miscarriage, a fetal demise or preterm birth? *

Who is your current OB/Gyn or Midwife? *

Have you been attending regular prenatal appointments? *

Have you undergone any prenatal tests or screenings? *

Are you pregnant with multiples? *

If yes, how many? (for example: twins, triplets...)

How did you hear about Blooming Babies Ultrasound?

Do you have any specific questions or concerns regarding your pregnancy or your appointment?