Congratulations on your pregnancy! Thank you for completing this form so I can get to know you better and have an idea of how I can best support you during your pregnancy, birth and postpartum.
Your Name
*
First Name
Last Name
Your Phone Number
*
-
Area Code
Phone Number
Your Birth Partners Name
First Name
Last Name
Your Birth Partner's Phone Number
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Area Code
Phone Number
Your Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Email
*
example@example.com
Your Birth Partner's Email
example@example.com
Your Pregnancy and Birth
Estimate Due Date
*
-
Year
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Month
Day
Date
Doctor/ Midwife's / Practice name
*
If not established type N/A
Delivery Location
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(Home, Birth Center, Hospital) If not established type N/A
Planned Method Of Feeding
Breastfeeding
Formula Feeding
Combination
Not sure but I would like more information
Are you currently experiencing any specific health or other concerns that affect this pregnancy? As with all of your information, anything you share will be kept confidential.
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Explain any complications you have had with this pregnancy or any restrictions your caregiver has given you.
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Pregnancy History
Have you given birth before?
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No
Yes, Vaginally only
Yes, Cesarean Only
Yes, Vaginally and Cesarean
Any history of miscarriage or infant loss?
Please Select
Yes
No
Birth Preparation
Have you taken or are you planning on taking any childbirth education classes?
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Please list any other classes you have taken or plan on attending.
Who do you plan to have assist you with your labor?
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Partner/Spouse
Mother/Mother-In-Law
Sister
Friend
Other
Who do you want present for the delivery?
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Do you have a birth vision planned?
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Yes, it is completed.
Yes, I have started one.
No, I would like like help writing one.
No, I have no interest in one.
In 5 words, please describe how you would like to FEEL and how you would like your birthing space to feel? (ex: calm, peaceful, energized, happy)
Have you talked about your birth preferences with your birth team? Are there any cultural/religious choices/preferences for your birth that I should know about?
What type of pain management are you looking to use?
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Comfort Measures
IV Medication
Epidural
Other
What is your vision for this birth?
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Anything else I should know in order to better support you?
Submit
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