What is the prenatal intake form template?
A first prenatal or booking appointment covers a lot of ground: dates, how the pregnancy was confirmed, every previous pregnancy, long-term conditions, medications, lifestyle, mental health and, increasingly, early thoughts about the birth itself. Asking all of it face to face leaves little time for the conversation that matters.
This template lets the patient answer at home, in her own time. Questions about previous pregnancies only appear if she's been pregnant before, and a note about urgent care appears if she reports bleeding. Sensitive questions — mood and safety at home — are included, with reassurance about confidentiality and a message offering a private conversation if needed.
Each intake is saved as a signed PDF in the vault folder you choose.
- Best for
- Midwives, obstetric and OB-GYN practices, maternity clinics
- Filled in by
- The pregnant patient
- Time to complete
- About 12 minutes
- Includes
- Dates and symptoms, previous-pregnancy logic, health and lifestyle, mood and safety questions, birth preferences, consent
Who uses a prenatal intake form?
- The booking appointment at the start of pregnancy care
- Independent midwives taking on a new client
- Transfers of care between practices or areas
- Practices offering telehealth first appointments
- Recording early birth-place and feeding preferences
- Replacing long paper booking forms completed in the waiting room
Questions on this prenatal intake form
39 questions over 5 pages · includes signature, conditional questions, multiple pages, consent checkbox.
1 About you
- Your full name*
- Date of birth*
- Mobile phone*
- Email*
- Home address*
- Partner or main support person
- Their phone
- Would you like an interpreter at appointments?
- Which language?* asked only when it applies
2 This pregnancy
- First day of your last period
- Estimated due date, if you know it
- How was the pregnancy confirmed?* Home pregnancy test · Blood test · Ultrasound scan
- How did you conceive? Naturally · With fertility treatment, such as IVF · Prefer not to say
- How many babies are you expecting? One · Twins or more · Not known yet
- Are you having any of these?* Nausea or vomiting · Bleeding or spotting · Cramping or abdominal pain · Headaches · Tiredness · None of these
3 Previous pregnancies
- How many times have you been pregnant before?*
- How many babies have you given birth to?* asked only when it applies
- Details of previous pregnancies and births asked only when it applies
- Did any previous pregnancy or birth involve…* asked only when it applies Gestational diabetes · Pre-eclampsia or high blood pressure · Birth before 37 weeks · Caesarean birth · Heavy bleeding after birth · Postnatal depression or anxiety · Pregnancy loss · None of these
4 Your health
- Do you have any of these conditions?* Diabetes · High blood pressure · Thyroid condition · Asthma · Epilepsy · Heart condition · Blood-clotting disorder · Anxiety, depression or another mental health condition · HIV, hepatitis B or C, or another long-term infection · None of these
- Medications and supplements you take
- Are you taking folic acid or a prenatal vitamin?*
- Do you have any allergies?*
- Allergy and the reaction* asked only when it applies
- Do you smoke or vape?* Never · Stopped before this pregnancy · Stopped since finding out · Yes, currently
- Alcohol since you found out you were pregnant* None · Occasionally · Regularly
- Blood group, if you know it A+ · A- · B+ · B- · AB+ · AB- · O+ · O- · Not known
- Inherited conditions in your or the baby's father's family
- Over the last two weeks, how often have you felt down, low or hopeless?* Not at all · Several days · More than half the days · Nearly every day
- Do you feel safe at home?
5 Birth preferences & consent
- Where are you thinking of giving birth? Hospital · Birth centre or midwife-led unit · Home · Not sure yet
- Pain relief you'd like to know more about Breathing, water, massage and movement · Gas and air (nitrous oxide) · Epidural · I'd like to discuss all options
- How are you thinking of feeding your baby? Breastfeeding · Formula · A combination · Undecided
- Who would you like with you in labour?
- Anything else about your care or birth you'd like us to know?
- Consent to care*
- Privacy*
- Signature*
- Date*
The prenatal intake form, page by page
1 About you
Name, date of birth, mobile, email and home address are required. A partner or main support person and their phone are optional. If she'd like an interpreter, the form asks which language.
2 This pregnancy
The first day of her last period and estimated due date are optional, since not everyone knows them. How the pregnancy was confirmed is required; conception and number of babies are optional. A required symptoms checklist includes bleeding or spotting — ticking it shows a message to contact the maternity unit or emergency services now if bleeding is heavy or pain is severe.
3 Previous pregnancies
The number of previous pregnancies is required (0 for a first pregnancy). Any number above zero reveals the number of births, details of each pregnancy, and a required checklist of complications such as gestational diabetes, pre-eclampsia, preterm or caesarean birth, heavy bleeding, postnatal depression or pregnancy loss.
4 Your health
A required conditions checklist covers diabetes, blood pressure, thyroid, asthma, epilepsy, heart and clotting conditions, mental health and long-term infections. Medications are optional; folic acid, allergies, smoking and alcohol are required. Blood group and family history are optional. A mood question asks how often she's felt down in the last two weeks — nearly every day shows a supportive message and where to get urgent help — and an optional question asks whether she feels safe at home — no shows a message offering a private conversation.
5 Birth preferences & consent
Optional questions cover where she's thinking of giving birth, pain relief she'd like to know more about, feeding, her birth partner and anything else about her care. Two consents cover pregnancy care and privacy, followed by signature and date.
Make the template yours
- Adapt the terms to your setting — antenatal or prenatal, midwife or OB
- Add your screening program's questions, such as genetic screening choices
- Change the mood question to the screening tool your service uses
- Add insurance or payment details if your practice needs them
- Route intakes to a folder per midwife or clinician
- Send it with the booking appointment confirmation
Tips for a better prenatal intake form
- Review mood and safety answers before the appointment so you can plan time for them
- Only ask about safety at home in a way the patient can answer privately
- Don't rely on the form alone for urgent symptoms — make sure patients know who to call
- Revisit birth preferences later in pregnancy; early answers often change
- Keep maternity records in a restricted folder with clinical access only
- This is a starting template — adapt it to your clinical guidelines and local health-privacy rules
Every response becomes a PDF in your vault
Each intake is filed as a signed PDF in your chosen vault folder, and the maternity team is notified. The patient receives a copy by email.
Clinicians can read the PDF before the booking appointment, and the Responses table makes it easy to spot answers that need follow-up, such as previous complications, low mood or safety concerns.
- Start from this template. It opens in the FileIt Forms designer — change any question, add pages, set the rules for when questions appear.
- Share it. Turn on a public link, or send it to people by email, each with their own link. They don’t need a FileIt account.
- Get the answers as PDFs. Each response is saved as a PDF in the vault folder you choose, with uploaded files attached — and listed in a Responses table you can export to CSV.
Prenatal intake form: frequently asked questions
Is this prenatal intake template free to use?
Yes. It's one of FileIt's ready-made templates, and every FileIt account, including the free plan, includes the Forms app and its full library of templates.
Do patients need a FileIt account to fill it in?
No. Patients complete it from a link or emailed request without an account. Only the practice needs one.
Why are the previous-pregnancy questions sometimes hidden?
They only appear when the patient says she has been pregnant before, so first-time parents aren't asked questions that don't apply.
Does the form alert us to urgent symptoms?
It shows the patient a message to seek urgent help if she reports bleeding. It doesn't alert your team automatically, so review new intakes promptly.
Is the mood question a validated screening tool?
It's a single question to prompt a conversation, not a full screening tool. Replace it with the tool your service uses if you have one.
Is this template clinically approved?
No. It's a starting point. Adapt it to your clinical guidelines, local screening programs and health-privacy rules.