Name
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Occupation
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Race & Ethnicity
Partner's Email
What is your partner's occupation and place of work?
Are you still working
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Yes
No
Do you plan to work after baby? If so when?
Partner's Phone
(###)
###
####
What is your preferred method of contact from now until labor begins?
*
Care Provider Info: Name, Phone Number, Address
*
Estimated Due Date
*
MM
DD
YYYY
If planning a hospital birth, what hospital do you plan to go to?
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Please describe your health in general, both before and during your pregnancy. Do you engage in physical activity? If so, what and how often?
*
To your knowledge, do you have/have you had any of the following:
Please list any allergies to medications, foods, latex, etc.
Please list any other chronic illnesses
Please list any medications/supplements you take regularly
Have you ever had anesthesia? Were there any complications?
Please list any prior surgeries with dates (including D&C procedures)
Have you had any prenatal tests so far? If so, what were they and what were the results?
Have you had any difficulties with this pregnancy? In your emotions or in your body? If so, please list/explain.
Please list any emotional/mental health challenges along with date, onset and treatment types. Note if you would like resources to help.
Are there any concerns about this in relations to your pregnancy, birth and parenting?
Any history of sexual abuse, physical/emotional trauma, PTSD? If so, please share within your comfort level so I can properly avoid any triggers. This includes scents, smells, colors, graphics, etc.
(If no prior pregnancies, skip the next 8) Have you had any miscarriages? If so how has this impacted you?
How many previous pregnancies?
Please share birth date, due date gender, name and birth weight for each
Please share about your birth experiences with all previous births.
Did you experience any disappointment and/or trauma during your previous birth experiences?
How has this impacted your current pregnancy?
Would you or have you done anything differently during this pregnancy/labor as compared to your previous pregnancy(ies)?
Are you planning to have a VBAC? Do you have any questions or concerns about this?
List and childbirth classes you have taken. If none, do you plan on taking any?
Have you informed your provider of your desire to have a Doula? If so, what was his/her response?
Do you have a birth preference/plan? If so, have you discussed it with your care provider?If you have one, please briefly discuss your birth plan. If not, do you want help to create one?
Who have you chosen to be with you during the birth? What role do you want them to play?
Is there anyone that you absolutely do not want at the birth or directly after the birth? Please list. Have you explained this to them?
How do you imagine I can be most helpful to you? How do you view my role in your pregnancy, labor, delivery, and postpartum period?
Do you have any religious or cultural beliefs/practices that you'd like for me to be aware of?
What kinds of sounds or smells do you like or dislike? Would you like essential oils diffused during labor?
When you are in pain or under stress, what comfort measures do you successfully use? Check those that you feel would be beneficial during labor
When frightened, how do you regain a sense of calm? Check any and all that apply
Where do you generally feel tension in your body?
How does pain and stress physically manifest for you?
In labor, what coping techniques do you anticipate using?
Do you have a name picked out? If so, do you want to share, or is it going to be kept a secret?
In an ideal situation, how would you like to welcome your baby?
Are you interested in delayed cord clamping or the lotus method?
Who will be cutting the cord?
Will you be taking your placenta home? If yes, for encapsulation or cultural?
Do you plan on breastfeeding?
Do you plan on circumcision?
Please check the boxes of what you want in regard to newborn procedures
Are you interested in cloth diapering?
Any special concerns about your child? Anything else I should know?
Mark any items that you would like to discuss during our visits: