Postpartum Care Pro Toolkit
A complete toolkit with a membership care agreement and an in-depth discharge review for established postpartum care centers.
Get started with PocperA complete toolkit with a membership care agreement and an in-depth discharge review for established postpartum care centers.
Get started with PocperThis 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.
Full name:
Date of birth:
ID or passport number:
Phone:
Address:
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-
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:
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:
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):
Any health concerns or follow-ups required:
Known allergies:
Pediatrician name:
Pediatrician contact:
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:
What does the mother hope to achieve during her stay?
Primary contact name:
Primary contact relationship:
Primary contact phone:
Secondary contact name:
Secondary contact relationship:
Secondary contact phone:
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.
The Postpartum Care Intake & Assessment template is a ready-to-use form from Pocper's Postpartum Care Pro Toolkit pack. Customize the fields to match your workflow, then share a link so clients can complete it and upload documents in real time.