ASHIKAI GLOBAL HEALTH & WELLNESS ADVOCACY
Daily Life, Nutrition & Health
How am I today? How is my baby today?
Indicates required field
How many weeks pregnant?
Baby movements and kicks felt - Choose all that apply:
Level of activity today:
General Health and Attitude:
Yes, regular bowel movement
Please record the following information for three days, preferably, consecutive days. Include all foods, water/fluids, and supplements.
This is provided for your convenience and should be beneficial in helping you assess your pregnant life! I also ask for this information so I will know how to serve you better.
I ask clients to submit this three day evaluation 2-3 times during pregnancy and postpartum, or when there may be difficulties that need to be addressed.
Don’t feel shy, it’s not a test! But it may be very eye-opening!! To get your 3 days recorded, you may submit this form three times noting which day you are recording.
Sleep & Rest:
</= 4 hrs
naps or rest times
First Meal & Snacking:
Second Meal & Snacking:
Third Meal & Snacking:
Fourth/Other Meal & Snacking:
Comment on any stressors or factors impacting your life:
How did you hear about Midwife York, this site/survey?
If Other please specify:
Goal: Well nourished, well supported mothers!
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