Fields in red are required.

About You



Your Partner








People you will have attend your birth





About Your Care Providers





Childbirth Classes?
YesNo

Breastfeeding Classes?
YesNo



About Your Health History






Medical History
AnemiaAsthmaAnorexia/BulimiaBladder/Kidney InfectionsBleeding DisordersCancerConization/LEEPDiabetesEpilepsyFibroidsHeart DiseaseHepatitisHerpesHIVHypoglycemiaHyper/HypotensionSTD’sTBThyroid DisordersUlcersVaricositiesVaginal Infections

Any history of personal trauma (rape, abuse, etc)
YesNo

About Your Pregnancy




Prior Pregnancies




Medication, Intervention, and complications


Prior Pregnancies




Medication, Intervention, and complications


Prior Pregnancies




Medication, Intervention, and complications


Have you breastfed before?
YesNo


Have you ever had postpartum depression?
YesNo

Have you had an ultrasound?
YesNo
How Many?

Result?

Other prenatal screening?

Group B Strep?
YesNo

Gestational Diabetes
YesNo

About Your Birth
Do you have a birth plan?
YesNo
Do you want photography or video?
YesNo
Who will be taking pictures or video?

How graphic?


What is your vision for this birth?

What are your expectations of your doula?

How do you feel about medical procedures/intervention in birth?

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?


Firstname Lastname Age
Jill Smith 50
Eve Jackson 94



Fields in red are required.

About You



Your Partner








People you will have attend your birth





About Your Care Providers





Childbirth Classes?
YesNo

Breastfeeding Classes?
YesNo



About Your Health History






Medical History
AnemiaAsthmaAnorexia/BulimiaBladder/Kidney InfectionsBleeding DisordersCancerConization/LEEPDiabetesEpilepsyFibroidsHeart DiseaseHepatitisHerpesHIVHypoglycemiaHyper/HypotensionSTD’sTBThyroid DisordersUlcersVaricositiesVaginal Infections

Any history of personal trauma (rape, abuse, etc)
YesNo

About Your Pregnancy




Prior Pregnancies




Medication, Intervention, and complications


Prior Pregnancies




Medication, Intervention, and complications


Prior Pregnancies




Medication, Intervention, and complications


Have you breastfed before?
YesNo


Have you ever had postpartum depression?
YesNo

Have you had an ultrasound?
YesNo
How Many?

Result?

Other prenatal screening?

Group B Strep?
YesNo

Gestational Diabetes
YesNo

About Your Birth
Do you have a birth plan?
YesNo
Do you want photography or video?
YesNo
Who will be taking pictures or video?

How graphic?


What is your vision for this birth?

What are your expectations of your doula?

How do you feel about medical procedures/intervention in birth?

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?


Firstname Lastname Age
Jill Smith 50
Eve Jackson 94