Birth Questionnaire
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Secondary/Partner's Phone Number
-
Area Code
Phone Number
Estimated Due Date
-
Month
-
Day
Year
Date
Email
example@example.com
About Your Birth
Upcoming and/or part births
Current Birth Plan (brief description)
Natural/Home Birth/C-section etc
Location
Birth Center & City
List any people attending birth of the baby
Parents, grandparents, siblings etc
How is your pregnancy progressing?
Normal with no complications
High Risk
Preterm labor/dilation
Some complications, but no concern as of now
Brief Description of past pregnancies (if any)
Pictures During Labor & Delivery
What I would like photographed
Yes, & okay to
share on
social media
Yes, but
not on
social media
Maybe
None
Labor
Family in
attendance
Care Providers
-with
permisssion
Nudity
Crowning
shots
Side shot
during delivery
Over the shoulder
during delivery
Nursing
First bath (if)
right after birth)
weight/height
Foot Prints
Family with
baby
Images with
care providers
Social Media
As you probably know, social media is my largest marketing tool for sharing my work. I would love the opportunity to share your (non-revealing unless permission granted) birth images in my portfolio and with my followers. This decision is completely up to you!
Would you like me to post a birth announcement and/or birth story blog post about your birth experience? (A birth announcement would be posted on social media within 5 hours of me leaving the session).
Yes, we would love that!
We would prefer to be the first to announce our news on social media, but you can post an announcement and blog after we share our news.
No thank you. We don't plan to share much over the internet.
Are you comfortable with me posting non-identifying social media updates about your labor and delivery experience?
Sure!
It's okay as long as you are subtle
Please don't post anything.
Do you want to be tagged in images on social media?
Yes, please!
No, thanks. I'll tag myself if I want to.
Type option 3
Type option 4
Submit
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