Birth Story Questionnaire
Mom's Name
First Name
Last Name
Mom's Cell Phone Number
-
Area Code
Phone Number
Email
example@example.com
Partner's Name
First Name
Last Name
Partner's Cell Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
Relationship to Mother
Do you know the gender/name of your baby?
Please specify gender/name here
Birth Information
Estimated Due Date
-
Month
-
Day
Year
Date
Birth Location
Hospital
Birth Center
Home
Other
Birth Location Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Care Provider (check all that apply)
Doctor
Midwife
Doula
Unassisted
Other
Doctor / Midwife Name
First Name
Last Name
Is this your first baby?
Yes
No
Labor Method?
Spontaneous Labor
Planned Induction
Planned Cesarean
Current Pregnancy
Normal with no complications
High risk
Low risk with some concerns
Previous Pregnancies
N/A
Normal with no complications
High risk
Low risk with some concerns
How long have previous labor/s lasted.
Have you spoken to your doctor about having a photographer attend your birth?
Yes
No
In the event of a C-section, have you spoken with your doctor about allowing photography in the OR?
Yes
No
Will you have a doula or other support team member present?
Yes
No
Do you plan on having your child(ren) present at the birth?
Yes
No
N/A
Please list names and ages of children that will be present.
Please list important family that will be in attendance at the birth (any grandparents, siblings, etc. ).
Ideally, how would you like me to capture the arrival moment"?
From the side
Mom's viewpoint
Crowning view
Please nominate the particular elements of the labor and birth you would specifically like me to capture? Check all that apply.
Partner Support
The baby's head as it crowns
Bonding moments with specific family members
The Placenta
Breastfeeding
Labor
Care team (with permission)
Cord cutting
Other
Would you like me to leave the room during particular situations or procedures?
Internal Exams
Epidural
Emergency Situation
Vomiting
Other
In the event that you are transferred from home/birth center to hospital or hospital to another hospital would you like me to:
Follow
Wait for instruction
Other
If an emergency occurs, do you want me to continue documenting?
Yes
No
Other
Do you want me to leave the room during golden hour?
Yes
No
Other
Please specify any laboring techniques you will possibly use. ( hypnobirthing, birth pool, epidural, etc.)
Any specific practices that will be performed? ( delayed cord clamping, lotus birth, etc.)
During birth — especially at home or in a birth center — the lighting is usually very dim. This often results in softer, grainier images when shooting only with natural light. While I love to use natural light when I can, using a flash (bounced gently off a wall) can create much clearer, sharper photos. How would you like me to approach lighting for your birth story?
Flash allowed
No flash
Minimal/only if absolutely needed
Other
Are there any goals or details within your birth plan that you would like to share with me? Knowing your plan can assist me in providing consistent support with the others in attendance.
When you imagine looking back at your birth photos years from now, what are the moments you most hope to see captured?
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