Schedule a free consultation today! * Schedule a free consultation today! * Schedule a free consultation today! * Name * First Name Last Name Date of birth MM DD YYYY Partner's Name First Name Last Name Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Partner's phone number (###) ### #### Planned Location of birth Leave blank if undecided Estimated Due Date * MM DD YYYY Do you have a birth plan? Yes No Do you have health insurance? If so, what do you have? Do you have allergies? If so, please list Have you had any recent illnesses, surgeries, injuries, accidents, or traumas? If yes, please describe Do you currently take any prescription or non-prescription medications (herbs, natural supplements, vitamins, OTC)? If yes, please list what you take and what it’s for Do you currently have, or do you have a history of, any of the following medical conditions? (check all that apply) High blood pressure Diabetes Asthma Anemia Chronic Migraine Menstrual problems Uterine fibroids Multiple sclerosis Seizure disorder/epilepsy Cancer HIV/AIDS Herpes HPV/ Genital Warts Abnormal blood clotting Other Do you currently have, or do you have a history of any of the following psychological conditions? (check all that apply) Anxiety Depression Bipolar disorder Schizophrenia PTSD Dissociative disorder OCD Major phobias Anorexia/Bulimia History of addiction Other Do you currently see a therapist or psychiatrist? Is there anything else you'd like me to know about your health history? Have you ever been pregnant before (include miscarriages, chemical, or ectopic pregnancies) * How many full term pregnancies have you carried (37+ weeks)? How many pre-term pregnancies have you carried (born 24-36 weeks)? How many living children do you have? Please list name(s) and age (s) Have you ever given birth to multiples (twins, triplets, etc)? Check all types of births you have experienced This is my first birth Vaginal (no prior c-section) C-section VBAC Elective induction Medically necessary induction Home birth Hospital birth Birth center birth Water birth How long did your previous labor(s) last? Have you had any of the following pregnancy-related health conditions in previous pregnancies? (check all that apply) Rh Incompatibility Pre-eclampsia Preterm Labor Low birth weight Macrosomia (large baby, 9+ lbs) Polyhydramnios (excess amniotic fluid) Oligohydramnios (Low amniotic fluid) Gestational Diabetes Placenta previa Placental Abruption Vena Cava Compression Postpartum Hemorrhage Postpartum Depression Genetic disorder Intrauterine Growth Restriction (IUGR) Hyperemesis Gravidarum (excessive vomiting) Gestational Hypertension (high blood pressure during pregnancy) Is there anything else you'd like me to know about prior pregnancies? Are you currently expecting multiples? Do you know the baby's gender? Girl Boy Don't know yet It will be a surprise Multiples Have you taken, or are you planning to take, any childbirth education classes? What type of birth are you planning? Vaginal Planned cesarean VBAC Water birth Being induced Are you experiencing any of the following pregnancy-related health conditions in your current pregnancy? (check all that apply) Rh Incompatibility Hyperemesis Gravidarum Gestation Hypertension Pre-eclampsia Intrauterine Growth Restriction (IUGR) Polyhydramnios Oligohydramnios Group B Strep Gestational Diabetes Placenta Previa Vena Cava Compression What role do you envision me taking during your birth? What are the 3 most important things to you for this birth? Who else would you like to be in the room? How involved does your partner wish to be in the birth? How would they like me to help them prepare? Do you have any religious or cultural beliefs you would like me to be aware of? Do you have any fears or anxieities about this birth you would like me to address? What type of comfort measures would you like to try during labor, or know more about? Breathing techniques Massage Birthing ball/Peanut ball Movement Water Hot/cold therapy Positive affirmations Aromatherapy Music Hypnobirthing Any other techniques you'd like to try or learn more about? Are you planning on breastfeeding your baby? Are there any topics you would like to focus on during prenatal visits? Any additional comments or questions? Thank you!
