Fields in red are required.
Partner's First Name
Partner's Last Name
Partner's Phone Number
About Your Care Providers
Primary Care Provider
Place of Birth *
About Your Health History
Allergies (drugs, food, latex)
AnemiaAsthmaAnorexia/BulimiaBladder/Kidney InfectionsBleeding DisordersCancerConization/LEEPDiabetesEpilepsyFibroidsHeart DiseaseHepatitisHerpesHIVHypoglycemiaHyper/HypotensionSTD’sTBThyroid DisordersUlcersVaricositiesVaginal Infections
History of emotional problems
Any history of personal trauma (rape, abuse, etc)
About Your Pregnancy
Medication, Intervention, and complications
Have you breastfed before?
Have you ever had postpartum depression?
Have you had an ultrasound?
Other prenatal screening?
Group B Strep?
About Your Birth
Do you have a birth plan?
Do you want photography or video?
Who will be taking pictures or video?
What is your vision for this birth?
What are your expectations of your doula?
How do you feel about medical procedures/intervention in birth?
Are there any cultural/religious choices/preferences that may affect your birth?
Anything else I should know to support you?