Postpartum Care Intake & Assessment

This intake gathers essential information about the mother and newborn so our care team can prepare a personalised stay. Please answer as completely as you can — you can update any section later with our staff.

Mother Information

Full name:

Date of birth:

ID or passport number:

Phone:

Address:

Pregnancy & Delivery

Delivery date:

Delivery type:

Vaginal

Planned C-section

Emergency C-section

VBAC (Vaginal Birth After Caesarean)

Complications during pregnancy or delivery:

OB/GYN name:

Clinic / hospital:

Blood type:

A — Rh+

A — Rh-

B — Rh+

B — Rh-

AB — Rh+

AB — Rh-

O — Rh+

O — Rh-

Newborn Information

Baby's name (or temporary name):

Date of birth:

Gestational age (weeks):

Birth weight:

Birth length:

APGAR score (1 / 5 min):

NICU stay:

Yes

No

If yes, reason and duration of NICU stay:

Feeding Plan

Preferred feeding approach:

Exclusive breastfeeding

Breast and formula combo

Exclusive formula

Undecided — would like guidance

Pumping support needed:

Yes — would like a pump on hand

Yes — bringing my own pump

No pumping planned at this time

Lactation challenges or concerns to share:

Maternal Health History

Pre-existing conditions:

Postpartum risk factors — please tick all that apply:

Gestational diabetes

Preeclampsia

Postpartum hemorrhage

Mental health history

Other

Current medications and dosage:

Allergies (food, medication, environmental):

Newborn Health History

Any health concerns or follow-ups required:

Known allergies:

Pediatrician name:

Pediatrician contact:

Dietary & Cultural Preferences

Dietary requirements:

Vegetarian

Vegan

Halal

Kosher

No restrictions

Cultural confinement preferences:

Traditional Chinese tonics

Korean miyeokguk-style menu

Japanese postpartum care

Western standard

Mixed / flexible

Specific foods to include:

Specific foods to avoid:

Stay Goals & Expectations

What does the mother hope to achieve during her stay?

Emergency Contacts

Primary contact name:

Primary contact relationship:

Primary contact phone:

Secondary contact name:

Secondary contact relationship:

Secondary contact phone:

Acknowledgement

The information provided above is accurate to the best of my knowledge

I will inform staff promptly of any changes to health, medication, or contact details

I agree to medical information being shared within the care team for safe care of mother and baby

Thank you. Your care team will review this intake and reach out to confirm any further details before the stay begins.