Congratulations on your pregnancy! Thank you for taking the time to fill out 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 Phone Number
Your Birth Partners Name
Your Birth Partner's Phone Number
Your Home Address
Street Address Line 2
State / Province
Postal / Zip Code
Your Birth Partner's Email
Current Pregnancy Information
Estimate Due Date
Doctor/ Midwife's / Practice name
Home, Birth Center, Hospital
Planned Method Of Feeding
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.
Explain any complications you have had with this pregnancy or any restrictions your caregiver has given you.
Have you given birth before?
Yes, Vaginally only
Yes, Cesarean Only
Yes, Vaginally and Cesarean
Any history of miscarriage or infant loss?
Have you taken or are you planning on taking any childbirth education classes?
Please list any other classes you have taken or plan on attending.
Who do you plan to have assist you with your labor?
Who do you want present for the delivery?
Do you have a birth vision planned?
Yes, it is a final copy.
Yes, but it is a draft and I would like some help.
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 caregiver? Are there any cultural/religious choices/preferences for your birth that I should know about?
How do you feel about interventions in labor/delivery? How would you like your doula to respond if you are requesting pain medication?
What type of pain management are you looking to use?
What type of comfort measures would you like to use in labor?
Walking, Dancing, Swaying
Aromatherapy (Essential Oils)
What is your vision for this birth?
Anything else I should know in order to better support you?
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