General Info

Birthing Person's Name

Date of Birth

Your Occupation

Your Email

Partner's Name

Partner's Occupation

Partner's Email

Estimated Due Date

Birthing Place

Midwife/OB

Health History

Have you had any surgical procedures to your cervix (LEEP, Cryotherapy, Coloscopy, Cone Biopsy, D&C)?

Have you had any breast surgeries? If so, please describe what and when:

Have you been diagnosed with any STIs? If so, please list with dates

Number of pregnancies:

Number of live births:

If you’ve given birth before, please answer the following questions:

How much did each of your babies weigh?

Around what gestational age were your babies born?

Did you body feed? If so, for how long?

How long were you in labor for each of your babies?

How did your labors begin?

Did you have any complications during the labor(s) or after the birth(s)?

Older children(s) name(s) and age(s):

Did you conceive via IVF or IUI?

Do you have an opportunity for rest periods or a nap each day?

Do you sleep well? How much sleep do you get at night?

Describe the exercise you engage in:

What medications/vitamins/supplements are you taking?

Have you had any alcohol, smoked cigarettes or taken any non-prescribed drugs during this pregnancy?

Any medical concerns with this pregnancy:

Are you under the care of a psychiatrist or psychologist?

Have you moved, changed jobs, or experienced any major life changes in the past 12 months?

How are you feeling physically and mentally this pregnancy?

Plans

How do you plan to feed your baby? (Bodyfeed, Donor Milk, Formula, Combination, Not Sure Yet)

If you plan to body feed, how do you feel about it generally? Have you taken any prep classes?

What, if any, are your goals for this birth?

What comfort measures do you use at home when you are in pain? Ex: dark, quiet, hot baths, cold, etc:

What are your biggest fears about this birth?

A history of trauma, abuse, poor family dynamic, and/or sexual history can impact how a person labors. It would be very helpful for me to know if this is the case so that I can best understand and support you. If you feel comfortable sharing this information with me, you can either provide it here, or you may prefer to discuss it by phone or in person. I also understand if you are not ready to disclose this type of information right away and that you may prefer that we get to know each other better before you feel comfortable sharing something so personal.

Questions for Partner:

How, if at all, have you been preparing for this birth (books, classes, videos, etc)?

Are you anxious about any aspect of this birth?

How do you feel about the change that parenting may have on your relationship with your partner?

Do you have any other questions or concerns?

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