Your estimated due date
Choice of birth place
Name of Hospital or Method Used at Home
Is this your first pregnancy?
Number of previous pregnancies
Number of children
Have you used fertility treatments?
If so, please list
Have you experienced any traumas during this pregnancy? (Please include any accidents or falls)
Have you had any evalution procedures?
Chorionic Villus Sampling
Please share your reasons for choosing these procedures, frequency, and effects
Is this pregnancy being treated as high-risk?
If so, why?
Have there been any stressful events in your life during this pregnancy?
Previous Births History
Were fertility methods used?
At what week of pregnancy were your previous babies born?
Previous choice of birth place
Home (describe method)
Name of hospital
Who attended your births?
Please check all that pertain to your previous births
Breech baby presentation
If other, please describe
Previous birthing positions
Lithotomy (on back with feet up)
On all fours
Birthing water tub
Did your babies experience any of the following?
Low APGAR Scores
Low Birth Weight
Failure to Thrive