Getting to Know You

General Information

Your Name

Your Birth Date (YYYY-MM-DD)

Baby’s Due Date (YYYY-MM-DD)

Home Address

Cell Phone

Partner’s Name

Partner’s Cell Phone

Names and ages of other children (e.g. Ava (8), Jack (4))

Pets? List breeds and names.

Have you chosen your birth team and location yet?

Yes

I could use help

OB/Midwife Name or Practice

Planned Birth Location

Hospital

Home

Other

Your Profession

Your Partner’s Profession

How does either profession affect this pregnancy? Positive (work at home, understanding boss, flexible hours, etc.) or Negative (stressful, long hours, travel, etc.) Please explain.

Religious affiliation or any special customs I should know about.

Do you have a special diet, allergies, or restrictions?

How did you hear about me?

Pregnancy Related Health History

How did you conceive?

Naturally

With medical support

Does diabetes run in your family?

Yes

Please list any health concerns or conditions I should know about.

Is this your first baby?

Yes

Describe your previous birth experiences (location, midwife/doctor, doula present, same father, length of labor, special techniques used, pain medications, surgery, etc.).

Have you experienced any of the following (feel free to leave this blank if you do not wish to discuss these experiences).

Miscarriage Abortion Sexual abuse Domestic abuse

I will ask at during first prenatal session if you like to discuss any of the above issues. It’s helpful for me to know because these issues can sometimes arise during labor.

Explain any spine, pelvis, back, or nearby pain issues in your life (e.g. broken tailbone, sciatica, endometriosis, etc.).

Prenatal Health, Education & Exercise

List any medications and supplements you’re taking now.

What is your exercise routine during pregnancy?

Emotional State of Mind

What are YOUR expectations about this birth?

What are your PARTNER’S expectations and concerns?

Any fears or anxieties coming up for either of you?

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

Yes No Not sure yet

Have you or will you take classes or read books about:

Pregnancy & Childbirth Breastfeeding Newborn Care

Tell me about the classes, books, or other media that appeal to you.

Communication & Expectations

How would you rate your communication with your care provider?

Wonderful

Okay

Could be better

Not great

What role do you see your partner playing during your birth process?

What are your expectations of support from your doula? What kind of encouragement works best for you? Are there any words or kinds of touch that you don’t like?

Your top three priorities for this birth are (not counting healthy mama/baby since that’s obvious):

Are there any extended family members planning to attend your birth? Do you have concerns about their energy or presence?

Postpartum Information

Do you have any concerns about your postpartum period? Are you anxious about any aspects of parenting or newborn care?

If you plan to breastfeed, please explain how important this is to you.

How much time are you and your partner planning to take off from work after the baby is born?

Is anyone planning to come and stay with you to help after the baby is born? If so, who, and what are your expectations for their support?

Are you concerned about postpartum depression? Why or why not?

Is there anything else you’d like me to know?