I look forward to working with you over the next few weeks. Your answers to the following questions will assist me in getting to know you better and will help me to attend to your needs, both physical and emotional, during the birth of your baby. Your answers will be held in strict confidence and will not be shared with anyone without your permission. Name of Mother* First Last Name of Father First Last Due Date* How do you feel about how your pregnancy has gone thus far?*Is it What You Expected?*Do you feel you are resting enough and able to relax?Are there any particularly stressful aspects of your life at this time?What types of self-care and self-nurturing activities are you doing for yourself?What kind of support system do you currently have in place? Who is available to help you with your children and your responsibilities for your family and home? Do you have anyone to turn to during times of stress?Have you had any life traumas that you feel I should be made aware of that could impact your pregnancy or your birth in some way (i.e., loss of a pregnancy or child, death of a loved one, physical or emotional abuse, substance abuse)?Have you had any procedures done to your cervix? Have you experienced any injuries to your neck, back, pelvis or tailbone?Have you had breast reduction surgery?*YesNoDate of SurgeryWhat is your vision for the remainder of your pregnancy? What support do you desire, what do you want to do to nurture yourself right now?Have you had an open discussion with your doctor or midwife about your desires for birth?Do you feel that you share similar goals?Do you trust that your care provider will support your choices?Have you met with other care providers in the practice?Have you met with other care providers in the practice?Have you toured the birth facility and do you feel comfortable about this location?Describe any concerns or fears you have surrounding your pregnancy. What steps have you taken to address these?Describe any concerns or fears you have surrounding the birth. What steps have you taken to address these?Check yes to all areas that you would be open to suggestions of holistic therapies (ie: dietary, chiropractic, herbal, acupuncture, etc.):* Prenatal Health (discomforts/concerns/general health) Induction of labor if medically recommended by your physician? Labor and Birth Postpartum Care Infant Care/Breastfeeding We will be discussing the risks and benefits and possible alternatives to typical medical procedures and practices that may be introduced during labor, birth, and postpartum. Which of the following topics are of greatest interest to you?* Drugs that may be introduced in lavor Inductions Epidurals Cesarean Cord Clamping Procedures after birth for me and my baby Circumcision Other:1. What is your vision for your birth, if it could go just as you’d like it to? How supportive would those in attendance be at home and at the hospital? Where will your children be? What will help you to feel safe and secure? How will you manage your comfort level? What will your birthing environment look at the hospital look and feel like?1. Describe your learning style. Are you more visual? Do you prefer to learn through demonstrations and charts? Do you like to read data or studies or see videos? Do you absorb more through listening to an instructor? Do you like more experiential learning such as through role play or art? Do you enjoy visualizations?Who will be present at this birth?Is there anyone that you wish to not receive information about what is happening during labor?Is there anyone you wish to exclude from this birth? If so, please explain.Is this your first birth experience?*YesNoHow close to your due date did labor begin?What were the first signs of labor starting?How long did labor last?How long was the pushing stage?What was most empowering about your previous birth experience?How do you want this pregnancy and birth to be different?Do you have a history of depression or postpartum depression? If yes, did you take steps to seek out treatment?Do you have any particular techniques for managing discomfort?Do you feel comfortable with being touched (i.e., massage, holding your hand, rubbing your feet, etc.)?Who will be there to support you in the early weeks following the birth?So that I can be sensitive to your needs, do you have any personal, cultural or religious beliefs that I should be aware of?Are there any other concerns/requests you may have that I can help you with:
