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 Name
*
First Name
Last Name
Your Phone Number
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-
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
Current Pregnancy Information
Estimated Due Date
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Year
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Month
Day
Date
Doctor/ Midwife's / Practice name
*
Delivery Location
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Home, Birth Center, Hospital
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 Prep
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
Doula
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 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?
What type of pain management are you looking to use?
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Comfort Measures
IV Medication
Epidural
Other
What type of comfort measures would you like to use in labor?
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Distractions
Breathing Patterns
Meditation
Massage
Birth Ball
Walking, Dancing, Swaying
Water (Tub/Shower)
Hot/Cold Therapy
Visualizations/Imagery
Focal Points
Aromatherapy (Essential Oils)
Music
What is your vision for this birth?
*
Anything else I should know in order to better support you?
Submit
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