Welcome Baby KC Needs Assessment

To individualize your care for the best experience possible, please take a moment to fill out this Needs Assessment. I will use this Needs Assessment as a tool to get to know you better.

Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Occupation

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Partner/Spouse's Name

First NameLast Name

Partner/Spouse's Cell

Area CodePhone Number

Estimated Due Date

Date

Provider's Name

Planned Place of Birth

Baby's Name (If Known)

Baby's Sex (If Known)

Planned Method of Feeding

BreastPump/BottlefeedFormula/BottlefeedMix of Both

About Your Health

Have you ever been treated for infertility? If so, please describe the treatments or procedures and when they occurred.

Please list any allergies or illnesses (chronic or otherwise) of which I should be aware.

Please list any prenatal testing and the results.

Explain in detail any complications with this pregnancy and any restrictions placed on you by your caregiver, including listing any medications you are currently taking.

Do you have any problems or former injuries in your hips, back, neck, or knees that I should be made aware of? If yes, please explain.

Do you want me to take pictures of the birth?

YesNo, Thank you.Unsure at this time

Please list any pictures you’d like for me to try to take during your labor and birth (e.g. partner cutting the cord, baby on scale, first breastfeeding, labor shots, etc.).

please note that while I will do my best to get the photos you ask for, I cannot guarantee that I will be able to.

Please describe, in detail, your previous pregnancy and birth experiences.

Preparations for Birth

Have you taken any childbirth education classes? Which class and when?

Who do you plan to assist with labor? Who will be in the room when you deliver?

Are you preparing a birth plan? Do you need my assistance?

Browse Files

Please rank the following as to what best suits your learning style with 5 being "most like me" and 1 being "least like me".

Visual: I learn by seeing

	1	2	3	4	5

1 is Least, 5 is Most

Auditory: I learn by hearing

	1	2	3	4	5

1 is Least, 5 is Most

Kinesthetic: I learn by doing

	1	2	3	4	5

1 is Least, 5 is Most

In nervous or painful situations, how does your body typically react?

In what areas of your body do you feel the most stress?

Do you have a history of abuse (physical, emotional, sexual)?

YesNoPlease keep answer confidentialI would like to discuss this with you more in private

Emotional Needs Assessment

Client

Partner

Client

Partner

Client

Partner

Client

Partner