Embedded Files
General Information
Name:
Partners Name:
Address:
Email:
Phone Numbers:
Birthday:
Emergency Contact Information
Name:
Phone Numbers:
Relationship:
Health Care Provider Information
Name:
Provider Type: -OB/GYN -CNM -CPM -Family Practice -Other:
Contact Info:
Location where you are planning to deliver
-Hospital -Freestanding Birth Center -Home -Other:
Name/Address of delivery location/ back-up hospital
Do you have health insurance?
General Health Information
Allergies:
Recent injuries, illness, surgery, trauma:
Medications (prescription/nonprescription):
Current or history of medical conditions:
Current or history of psychological conditions:
Other conditions not listed:
Anything else I should be aware of concerning your general health?
6. Previous Pregnancy Information
How many times have you been pregnant?
How many times have you given birth?
How many times have you carried to term(37 weeks+)?
How many of your births were preterm (24-36 weeks)?
How many children do you have? Please list names and ages
Have you ever been pregnant with multiples?
What type of birth have you experienced, please circle all that apply:
-First Birth -Vaginal Birth -Assisted Delivery (forceps/vacuum) -Cesarean Section
-VBAC -Medical Induction -Elective Induction -Home Birth -Hospital Birth -Birth Center
-Water Birth -Precipitous Labor - Long Labor -Non medicated - With an Epidural
How long did your previous labors last?
Have you had any of the following pregnancy related health conditions in your past pregnancies? Circle all that apply:
-Rh incompatibility -Preeclampsia -Preterm Labor - Low Birth Weight
-Macrosomia (large baby) -Polyhydramnios -Oligohydramnios -Group B Strep
-Gestational Diabetes -Placenta Previa -Placental Abruption -Vena Cava Compression
-Postpartum Hemorrhage -Postpartum Depression -Genetic Disorders
-Intrauterine Growth Restriction (IUGR) -Hyperemesis Gravidarum
-Gestational Hypertension -Other (please explain)
7. Current Pregnancy Information
Due Date (estimation is fine):
Singleton or Multiples:
Gender of baby: Name: Are you sharing this information?
Have you taken, or are you planning on attending any childbirth education classes? If so, what class and where will you be attending?
What type of birth do you desire?
-Vaginal -VBAC -Cesarean -Elective Induction -Medical Induction -Water Birth
How do you plan on laboring and giving birth?
-Natural (comfort measures, but no pain medication) -Epidural - One moment a time
-Other (please explain):
Have you had any of the following pregnancy related health conditions in your current pregnancy? Circle all that apply.
-Rh incompatibility -Preeclampsia -Preterm Labor - Low Birth Weight
-Macrosomia (large baby) -Polyhydramnios -Oligohydramnios -Group B Strep
-Gestational Diabetes -Placenta Previa -Placental Abruption -Vena Cava Compression
-Postpartum Hemorrhage -Postpartum Depression -Genetic Disorders
-Intrauterine Growth Restriction (IUGR) -Hyperemesis Gravidarum
-Gestational Hypertension -Other (please explain)
8. Birth Wishes
Do you have a birth plan/vision? Or “birth goals”? (if yes, please attach a copy)
-Yes -No -Would like help
What are the top 5 important outcomes that you desire for this birth?
Please describe the role you envision for your doula at this birth?
Who else will be with you during labor/birth? What role do you expect them to take?
Is there anyone you do NOT want to be present during your labor, birth, and postpartum period?
What role does your partner envision for your doula at this birth?
Do you have any religious or cultural beliefs that I should be aware of?
Have you had any difficulties, complications, or restrictions (physical, emotional, or otherwise) with/during this pregnancy?
Do you have any fears or concerns about this upcoming labor and birth?
What types of comfort measures do you think you would like to use during labor?
-Breathing Techniques -Massage -Birth Ball -Peanut Ball -Walking -Dancing/Swaying
-Water therapy (Shower/tub) -Hot/Cold Therapy -Distractions -Visualizations/Imagery
-Focal points -Aromatherapy -Spinning Babies -Rebozo -Music
-Other, Please describe
Are you planning on breast/chest feeding your baby?
Are there any particular topics that you would like to focus (or receive more information) on during our prenatal visits and conversations?
Comments/questions/concerns about ANYTHING AT ALL:
Page updated
Google Sites
Report abuse