Name *

Phone *

Date of Birth *

Birth Partner's Name (if applicable)

Birth Partner's Phone Number (if applicable)

Other Children? Name & Age (if applicable)

Home Address *

Email *

Birth Partner's Email

Occupation (Optional)

Current Pregnancy Info

Estimated Due Date *

Who are you expecting? Girl, Boy, or Surprise? *

Doctor / Midwife's / Practice name *

Delivery Location / Address *

Planned Method of Feeding
BreastfeedingFormula FeedingCombinationNot sure, I would like more information

Are you currently experiencing any specific health or other concerns that affect this pregnancy? As with all your information, anything you share will be kept confidential. *


Explain any complications you have had with this pregnancy or any restrictions your caregiver
has given you. *

Pregnancy History

Have you given birth before? *
NoYes, Vaginally onlyYes, Cesarean OnlyYes, Vaginally and Cesarean

How was your last birth experience? (Optional)

Any history of miscarriage or infant loss?

Do you currently have any sexually transmitted diseases? *

If you have been pregnant before, did you experience any complications with the pregnancy,
birth, or postpartum period? (Optional)

Is there anything in your personal history that might make it hard for you to cope with the
experience of labor and/or nursing? (Optional)

Birth Prep

Have you taken or are you planning on taking any childbirth education classes? *

Please list any other classes you have taken or plan on attending

Who do you plan to have assist you with your labor? *
Partner/ SpouseMother/ Mother-in-LawFriendDoulaSisterOther

What type of pain management are you looking to use? *
Comfort MeasuresEpiduralOIV MedicationOther

What type of comfort measures would you like to use in labor?
DistractionsBreathing PatternsMassageBirth BallWalking, Dancing, SwayingHot/Cold TherapyVisualizations/ImageryFocal PointsAromatherapy (Essential Oils)MusicCounter PressureEncouraging WordsWater (Tub/Shower)

In 5 words, please describe how you would like to FEEL and how you would like your birthing
space to feel? (ex: calm, peaceful, energized, happy)

What is your vision for this birth? *


Are there any cultural or religious aspects of your life you would like me to know about?

Anything else I should know in order to better support you?

Δ