Birth Experience Quiz

1
Let's start with your name babe* This field is required.
First Name or Nickname
Last Initital is enough!
2
Thank you! Let's see of you have the right resources in place to support your birth preferences. Are you ready to get started?* This field is required.
YESNO
3
How far along are you in your pregnancy today?* This field is required.
Please Select
Please Select
Not currently pregnant, just planning ahead!
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months
4
Have you ever been pregnant before?* This field is required.
This is my first pregnancy
I have been pregnant once before
I have been pregnant multiple times
I have never been pregnant
5
What your pregnancy experience to date?* This field is required.
All successful births carried to term no complications
Successful and carried to term, some complications
It has been challenging carrying my pregnancies to term
No experience yet
6
Where would you prefer to give birth?* This field is required.Rank in order by preference.
7
How much pregnancy & birth support do you want to have?* This field is required.
Daily tips please
Weekly guidance
Monthly advice will do
Only necessary check-ups and appointments for me please
Just right before and during delivery
8
Who do you look to for guidance and answers to your questions?* This field is required.Please drag to rank in order of preference
9
What puts your mind most at ease?* This field is required.Please drag to rank in order of preference
10
What is your biggest concern about birth?* This field is required.
Please Select
Please Select
Not being prepared when labor arrives
Feeling unsupported or unheard by my birth team
Lack of freedom and limited options in birth setting
Inability to manage discomfort during labor and birth
Giving birth preterm or going far past my past expected due date
11
Have you taken any childbirth education classes?* This field is required.Check all that apply
Yes, with my hospital/birthing center
Yes, online only
Yes, in person and online
Yes, I am taking private classes (hypnnobirthing, spinning babies, etc)
No, don't know where to start
I'm not planning to
12
How do you feel about epidurals?* This field is required.
Please Select
Please Select
Sign me up please!
No, but I am open to other less evasive medical options
No way! I prefer natural pain relief methods
13
Do you currently engage in any of the following? * This field is required.
Yes
Sometimes
Never
I talk to my baby regularly
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
I talk to my partner (or co-parent) about my baby
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
I talk to my friends & family about my baby
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
I am making postpartum plans for my baby
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
I talk to my baby regularly
I talk to my partner (or co-parent) about my baby
I talk to my friends & family about my baby
I am making postpartum plans for my baby
Yes
Row 0, Column 0
Sometimes
Row 0, Column 1
Never
Row 0, Column 2
Yes
Row 1, Column 0
Sometimes
Row 1, Column 1
Never
Row 1, Column 2
Yes
Row 2, Column 0
Sometimes
Row 2, Column 1
Never
Row 2, Column 2
Yes
Row 3, Column 0
Sometimes
Row 3, Column 1
Never
Row 3, Column 2
1 of 4
14
Do you have a birth plan in place already?* This field is required.
Yes I do!
No, still working on it
I need help making one
Not important to me
15
Do you have a postpartum plan in place?* This field is required.
Yes, ready to execute
No, but I am planning to
Wow, I didn't think I needed one - please help!
I am not interested in creating one
16
What are you looking forward to the most about your birth experience?Please be honest, we all have our own things we look forward too, there are no bad answers
Please Select
Please Select
Finally meeting my baby!
Birthing on my own terms
Having the custom environment I desire
Having an amazing birth team
The birth photos!
17
Do you feel confident that the resources and guidance you have received so far about pregnancy have prepared you for the unknown?* This field is required.It's ok if you don't, that's what this is for
YESNO
18
How happy are you with birth support team?Slide the smiley
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
19
Please use this optional space as a journal prompt to share any fears, concerns, desires or dreams for your birth! Is there anything is your past experience that is influencing this pregnancy? Is there anything going on now that is affecting you? Keep it real and be sure to reflect back on your submission.If you don't want to write anything, that's ok too!
Huge
Large
Normal
Small
Ok
Ok
20
Would you like Werk it Moms to follow up with you about doula services?* This field is required.
YESNO
21
What's your email so I can make sure you get your results* This field is required.
example@example.com
22
Just hit SUBMIT and you will get an email with your results. I encourage you to reflect and use this as tool to evaluate your needs for birth, pregnancy and postpartum. You got this!

Much love,

Your Doula, Nicky
Should be Empty: