New Client Questionnaire

Thank you for taking the time to complete this questionnaire. It helps me to support you better!

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GENERAL INFORMATION

Name*

Name

Partner/Support Person's Name*

Name

Your Home Address*

Street Address Address Line 2 City State ZIP Code

Partner/Support Person's Home Address

Street Address Address Line 2 City State ZIP Code

Phone*

Partner/Support Person's Phone*

Your Email*

Enter Email Confirm Email

Partner/Support Person's Email*

Enter Email Confirm Email

Your Date of Birth*

Month

Day

Year

Partner/Support Person's Date of Birth*

Month

Day

Year

Your Occupation*

Partner/Support Person's Occupation*

HEALTH CARE PROVIDER INFORMATION

Name of Provider*

Type of Provider*

Midwife

Doctor

Other

If other, please specify

Provider Address*

Street Address Address Line 2 City State ZIP Code

Provider Phone Number*

Location where you plan to deliver?*

Home

Hospital

Birth Center

Other

Name and address of delivery location and backup hospital if you plan to deliver at a birth center or at home*

Other Providers (i.e., Chiropractor, Acupuncturist, Homeopath/Naturopath, Massage Therapist, etc.)*

GENERAL HEALTH INFORMATION

Do you have allergies, sensitivities, or diet restrictions?*

Yes

If yes, please list*

Have you had any recent illnesses, surgeries, injuries, accidents, or trauma?*

Yes

If yes, please describe*

Do you currently take any prescription or non-prescription medications (herbs, natural supplements, vitamins, over the counter, including prenatal vitamins)?*

Yes

If yes, please describe*

Exercise type and frequency (including walking)*

Describe your level of activity throughout the day. Do you sit at a desk all day? Are you standing a lot? How often do you participate in recreational activities and of what sort?*

Are you currently receiving care for any medical condition or a contagious disease?*

Yes

If yes, please describe*

Prior to pregnancy, did you notice any patterns with how you felt physically, mentally or emotionally throughout the length of your menstrual cycle? Did you have a 28-day cycle with ovulation on day 14? If no, please explain your cycle length and ovulation timing.

Do you have any specific neck, back or pelvic issues?*

Yes

If yes, please describe*

Have you previously had or currently have a heart condition, a pacemaker, high blood pressure, low blood pressure, glaucoma, epilepsy or seizures?*

Yes

If yes, please describe*

Do you have hyper mobility? (People who are hyper mobile can bend their thumb to their forearm or reverse their knees and elbows slightly.)*

Yes

If yes, please describe*

Do you have HSV (Herpes)?*

Yes

Have you had any outbreaks while pregnant?*

Yes

Do you smoke/vape*

Yes

Does your partner/support person smoke/vape?*

Yes

What does a general day of food & beverages look like for you?

Breakfast:*

Lunch:*

Dinner:*

Snacks:*

Water/Beverages:*

How many hours a night do you sleep? Do you sleep well during that time?*

Explain anything else you would like me to know about your general health condition(s).

Do you currently see a therapist or a counselor?*

Yes

Have you had any life traumas or psychological conditions 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, emotional or sexual abuse, substance abuse, anxiety, depression, bipolar disorder)? During labor and birth these issues can come into play. As your support person, I may be of help during labor and delivery if I know this issue exists. If you feel comfortable in sharing this matter with me, I will keep it confidential.

PREVIOUS PREGNANCY INFORMATION

Total number of pregnancies:*

Total number of live births:

Out of previous pregnancies, how many were carried to term (37 weeks +)?

Out of previous pregnancies, how many were preterm (born 24 – 37 weeks)?

How many children do you have?*

Please list name(s) and age(s):

Have you given birth to multiples (twins, triplets, etc)?*

Which types of births have you experienced? (check all that apply):*

This will be my first birth

Vaginal

Cesarean

VBAC (Vaginal Birth After Cesarean)

Elective induction

Induction for medical reasons

Home birth

Hospital birth

Birth center birth

Water birth

How long did your previous labor(s) last?

How long did you push, if applicable?

Did you have any pregnancy-related health conditions in PAST pregnancies (i.e. Rh incompatibility, Pre-Eclampsia, Preterm Labor, Group B Strep, Gestational Diabetes, Placenta Previa, Postpartum Hemorrhage, Postpartum Depression, Hyperemesis Gravidarum (excessive vomiting), etc.)?

Please tell me anything you would like me to know about your PAST pregnancies:

CURRENT PREGNANCY INFORMATION

Baby's Due Date*

Month

Day

Year

Are you expecting multiples (twins, triplets, etc)?*

Gender of the Baby*

Girl

Boy

One of each (twins)

We want a surprise!

Do you have a name picked out? If yes, you can share it with me here if you like:

Do you plan to share the name with others?*

Yes

We would like it to be a surprise, please don’t share!

Have you taken, or are you planning on taking, any childbirth education classes? If so, what classes and where will/did you attend them?*

Yes

Please check all that apply:

childbirth education class

Childbirth Education Class

What type/name of childbirth Education Class?

Breastfeeding class

Breastfeeding Class

Instructor's Name?

prenatal yoga

Prenatal Yoga

Location?

Other prenatal exercise class

Other Prenatal Exercise Class

Type & Location?

parenting class

Parenting Class

Instructor's Name

newborn care class

Newborn Care Class

Instructor's Name

infant cpr

Infant CPR

Location?

What pregnancy or childbirth books have you read?

What type of birth are you hoping for? (check the applicable answer)*

Vaginal

Cesarean Birth

VBAC

Elective Induction

Induction for Medical Reasons

Water

Do you plan to birth (check the applicable answer):*

Non-medicated

Epidural

Other pain medication

Have you had any pregnancy-related health conditions/complications/discomforts in this CURRENT pregnancy (i.e. Rh incompatibility, Pre-Eclampsia, Preterm Labor, Group B Strep, Gestational Diabetes, Placenta Previa, Hyperemesis Gravidarum (excessive vomiting), etc.), or have you been given any restrictions by your provider? And what, if any, treatments have you sought?*

Have you tested positive for Group B Strep (GBS)?*

Yes

Results of Blood Glucose Screen*

Have you had any vaginal bleeding at any point during this pregnancy?*

Do you have an anterior placenta?*

How do you feel your pregnancy has gone thus far? Is it what you expected?*

What have you liked most about this pregnancy?*

What have you liked least about this pregnancy?*

Do you feel you are resting enough and able to relax or are there any particular stressful aspects of your life at this time?*

What type of self-care and self-nurturing activities are you doing for yourself?*

BIRTH WISHES

Do you have a birth plan/vision?*

Yes

No- Need help with a plan

What are the 3 most important ways you want this birth to look like or feel like for you?*

Please describe the role you envision for me at your birth:*

Who else will be with you at the birth, and what role would you like them to play?*

Is there anyone that you do NOT want to be present at the birth, or during the immediate postpartum period?*

What would your partner like me to do to help them be more supportive to you during labor?*

Have you had an open discussion with your doctor/midwife about your desires for birth? Do you feel that they share similar goals? Do you trust that your care provider will support your choices? Have you met other care providers in the practice? Have you toured the birth facility, and do you feel comfortable about this location?*

Have you had any difficulties/complications/restrictions (physical, emotional, or other) with and during this pregnancy?*

Do you have any fears about this birth?*

What type of comfort measures do you think you would like to use during labor? (check all that apply):*

Distractions

Walking, Dancing, Swaying

Focal Points

Breathing Patterns

Water (tub/shower)

Aromatherapy

Massage

Hot/Cold Therapy

Music

Birth Ball

Visualization/Imagery

Acupressure

TENS Unit

Other techniques you would like to use:

Do you feel comfortable with being touched (i.e. massage, acupressure, holding your hand, rubbing your feet, etc.)?*

Do you have plans to keep your placenta for encapsulation or burial and/or another reason of your choice? If you plan to encapsulate it, would you like me to help you with that process? I offer this service for an additional fee.*

Are there any particular topics that you would like to focus on during our prenatal visit(s)/conversations?*

Do you have any personal, religious or cultural beliefs that you would like me to be aware of?*

Are there any routine newborn procedures you’d like to delay or refuse (i.e. Vitamin K shot, Hepatitis B shot, eye ointment)? Do you need further information to decide on any of these procedures?*

If your baby has a penis, are you planning to circumcise?*

Yes

Need further information to decide

Planned method of feeding baby:*

Breastfeeding

Formula Feeding

Both

What kind of help/support do you have after baby is born (immediate days to weeks)? Do you plan to hire a postpartum doula to help support you, if so, would you like to discuss my availability for postpartum doula support?*

Are you ok with having a student doula at prenatals and/or the birth?*

Yes

Need further information to decide

Comments/questions about absolutely anything!

New Client Questionnaire

Thank you for taking the time to complete this questionnaire. It helps me to support you better!

GENERAL INFORMATION

HEALTH CARE PROVIDER INFORMATION

GENERAL HEALTH INFORMATION

PREVIOUS PREGNANCY INFORMATION

CURRENT PREGNANCY INFORMATION

BIRTH WISHES

Contact Me for a Free Consultation