Mother's Name
*
First Name
Last Name
What is your Occupation?
Father/Birth Partner Name and Occupation
Email Address
*
Best Contact Phone number. May we text you?
*
Number of Pregnancies, including miscarriage, infant loss, preterm labor, Postdate births (beyond 42 weeks)
Place for Birth
Who else will attend this birth. Family, friends, children, etc. Please list.
How had this pregnancy gone so far?
Personal Information
Do you currently or have ever had any of the following
Psychological History
You are by no means obligated to answer these questions. Everything you share and we discuss is confidential.
Are you currently taking any medications?
Additional Concerns, fears, worries. Please comment below
Health Review
How do you feel this pregnancy has been? How are your eating habits and exercise routines? Do you have any restrictions?
How involved does the partner plan to be? Does he/she have any specific worries or concerns?
What kinds of things help you relax or feel better? Laughter, touch, having quiet time, etc. Please let me know what helps you.
What are your feelings about medication relief?
Have you taken any childbirth education classes?
Do you have a birth plan prepared?
What is your feeding plan? Breast, bottle, unsure.
What is your plan for postpartum?
