Personal Information
Tell me about yourself
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Father/ Partner
First Name
Last Name
Partner Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
-
Month
-
Day
Year
Date
Pregnancy
Estimated Due Date
-
Month
-
Day
Year
Date
I’m being cared for by a
Midwife
Obstetrician
Family Doctor
Undecided
Health Care Provider
First Name
Last Name
Providers Phone Number
-
Area Code
Phone Number
Providers Office Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Pregnancies
Number of Live Births
Prior Pregnancy/Birth Complications
Have you been diagnosed with any of the following during this pregnancy
Gestational Diabetes
Placenta Previa
Gestational Hypertension
Preeclampsia
Group B Strep
Other
Birth
Let’s make a plan
Where are you planning to deliver?
Birth Location Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
As long as everything goes smoothly I would like to avoid
Cervical Ripening
Pitocin Induction
Artificial Membrane Rupture (breaking of water)
IV Pain Medication
Epidural Pain Medication
I want a completely unmedicated birth and do not want to be offered medication at all
No thanks, I’d like all the drugs please!
I’m interested in using the following natural comfort measures
Water Immersion
Massage
Rebozo
Birthing Ball
Aromatherapy
Hypnotherapy
Other
I’d like the baby to be monitored
Constantly
Intermittently
Wirelessly
Via Doppler
To set the mood for my birthing room I’d like
Soft Music
Scripture/ Affirmation Printouts
Dim Lighting
Twinkle Lights
Flameless Candles
No Frills
Other
During labor I’d like to
Eat
Drink
Walk / Move
Be as undisturbed as possible
Be pampered
Other
I’d like to give birth
In a bed
In a birthing tub
On a birthing stool
Standing up
Squatting
On hands and knees
Wait and see
When it’s time to push I’d like to
Push spontaneously
Have coached pushing
Breathe the baby out
Wait and see
When the baby is out I’d like
Immediate skin to skin
To breastfeed
For baby to be wiped down first
Delayed cord clamping
Other
I’d like my placenta to be
Expelled in its own time
Encapsulated
Out of sight
Other
For My Baby
Do you plan to vaccinate in the hospital
Yes
No we are waiting
No we are not vaccinating
Undecided
I do not want my baby to have
Vitamin K
Eye ointment
Pacifier
Formula supplements
If baby is a boy we plan to
Circumcise in hospital
Circumcise our of hospital
Leave baby intact
Undecided
In your own words describe your ideal birth.
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