* Client Name
Planning to deliver at:
Are you happy with your OB/Midwife?
Are you seeing any other providers?
i.e. therapists, acupuncturist, etc.
How is your usual period cycle?
How has your elimination been during pregnancy?
How much sleep are you getting?
Are you allergic to anything?
Have you had any medical issues with your pregnancy?
List any prenatal tests done, with results:
Have you had any past procedures that would have resulted in scar tissue on your cervix?
Have you had any past procedures that would have resulted in scar tissue on your uterus?
Where do you usually carry body tension?
How do you manifest body tension?
In a (physically and/or emotionally) painful situation, how do you comfort yourself?
If you have a boy, do you intend to circumcise him?
Undecided, lets talk about it
Do you have a plan for your hospital stay?
How do you feel your pregnancy is going? Is it what you had expected it to be so far?
Are you feeling rested or restless? Any pregnancy dreams?
What are the most stressful aspects of your life right now? What are you doing to counteract that stress, if anything? What could you be doing?
Who do you turn to for support? Do you expect them to be able to support you when your baby arrives?
Have you had any childbearing losses? (abortion, miscarriage, infertility, stillbirth)? And how long ago?
This may be triggering, take time to respond, or in person alone, or maybe you’re not quite ready at all, and that’s okay too.
Have you experienced any significant losses?
Past Trauma Information
The following questions are solely informative. Honest answers will help us to better understand your needs and help you while you labor. In the event that you do not want to put these answers down on paper, please phone your doula or you may send these answers in a separate email directly to your doula.
WE DO NOT SHARE THIS INFORMATION.
Have you had any life traumas that have resulted in PTSD?
Have you suffered from or are currently suffering from any sexual abuses?
Have you suffered from or are currently suffering from any physical abuses?
Have you suffered or are suffering from any eating or body image disorders?
Anticipated Birth Information
Who would you like to be present at this birth?
Imagine your ideal birth- what are its most important aspects for your happiness, comfort, and peace of mind?
What are your greatest fears about birth?
In the event of a Cesarean section, what things would be most important to you?
Reflect on a time when you felt especially calm. What were the circumstances?
Reflect on a time when you were especially powerful. What were the circumstances?
What coping techniques for labor do you plan to use?
water, massage, visualization, pain medication, etc.
How do you envision me being most helpful to you during your birth?
What are your thoughts about the Baby’s gender and name?
Do you plan to breastfeed exclusively, use formula exclusively, or both?
Will someone be with you to take care of you in the postpartum?
Anything else you’d like me to know?