Your Name (required)

Estimated Due Date

Is your baby a boy, girl or a surprise?

Date of Birth

Occupation

Husband/Partner Name

Husband/Partner Name Occupation

Your Address

Your Email Address (required)

Partner's Email Address

Copy partner on emails?
YesNo

Home phone

Cell phone

Partner's cell phone

Best way for me to contact you
PhoneTextEmail

Religious Affiliation

Special Customs

Name/Nickname of your baby

Does anyone else live in your home?
YesNo

Name of OB/Midwife

Their phone

How would you rate your communication with your OB/Midwife?
FairOKGoodGreat

Have you toured and registered at the hospital?
YesNo

Which & where?

Have you taken a breastfeeding class?
YesNo

Which & where?

Do you have any questions about the care you are receiving?

Have you taken any other prenatal or newborn classes (massage, yoga, etc.)?

Have you ever considered home birth?

Have you ever considered using a brain training program such as Gentle Birth or Hypnobabies for birth?

Have you ever been diagnosed with:
Genital herpesHIVHPVGestational Diabetes Group B Strep

On a regular basis do you prefer:
Over the counter medicationNatural alternatives

How do you respond to everyday pain (headaches/flu/colds etc.) when you are not pregnant? Please explain your emotional response as well as what you normally do to physically relieve the pain.

Pre-pregnancy weight

Current weight

Are you RH-?
YesNo

Have you ever had a breast reduction?
YesNo

Have you ever had a breast augmentation?
YesNo

Have you seen other care providers (i.e. acupuncturist, chiropractor)?

Do you want/need additional information about:
PregnancyNutritionExercisBreastfeedingBaby CarePostpartum period

Share your blog or family website URL if you have one:

Do you have faith in your body and trust that you and your baby instinctively know how to give birth?
YesNo

If no, please explain.

What are you and your partner's hopes or expectations for this birth? (Tell me what you're wishing for...

What are you and your partner's fears/anxieties?

What are you and your partner's wants/desires?

Have you ever seen someone or an animal give birth before in real life (not TV or movie)?
YesNo

If Yes, please explain:

What do you know about the birth experience of your mother and your partner's mother?

Please describe any other birth experiences that you are aware of that have strongly impacted you:

What are you expecting from your doula during birth?

What role do you see your partner playing during birth?

Do you have any food allergies?

Do you have any medical allergies?

Do you have a special diet?

Please list any supplements, vitamins or medications you currently take:

Please check any cervical procedures you have received:
Removal of tissue after a miscarriageIinsertion of an IUDTreatment for abnormal Pap smear or genital warts (i.e.cryosurgery/LEEP procedure)Cervical or uterine biopsyRemoval of polypsAbortion

How would you describe your personality?

Have you ever dealt with vaginismus (pain during sex)?
YesNo

Did you drink alcohol prior to pregnancy?
YesNo

Have you ever taken the birth control pill?
YesNo

If Yes, for how many years?

Do you exercise?
YesNo

Have you ever been diagnosed with:
depressionanxietybipolarOther

Are you receiving care for any other physical or mental health issues?
YesNo

Do you or your partner have friends or family involved in the birth that you would like me to be aware of?

Have you ever been pregnant before?
YesNo

Have you given birth before?
YesNo

Do you plan to breastfeed?
YesNo

Any concerns about breastfeeding?

Have you or your family experienced postpartum depression before?
YesNo

Have you ever considered placenta encapsulation to help balance hormonal imbalances, mood and healing after baby is born?
YesNo

Have you experienced any complications with this pregnancy?

Are you experiencing any discomforts?

Have you ever suffered a serious accident or injury (car, horseback riding, fall) as a child or adult?

Do you have any special concerns or questions you would like to discuss during our visit?

Why did you decide to hire me? 🙂