Personal Information
Name
Birth Practitioners
Midwives
Doula
Medical Practitioners
Your estimated due date
Choice of birth place
Name of Hospital or Method Used at Home
Is this your first pregnancy? Yes No
Number of previous pregnancies
Number of children
Have you used fertility treatments? Yes No
If so, please list
Have you experienced any traumas during this pregnancy? (Please include any accidents or falls)
Have you had any evalution procedures? Ultrasound Amniocentesis Chorionic Villus Sampling Other
Please share your reasons for choosing these procedures, frequency, and effects
Is this pregnancy being treated as high-risk? Yes No
If so, why?
Have there been any stressful events in your life during this pregnancy?
Previous Births History
Were fertility methods used? Yes No
At what week of pregnancy were your previous babies born?
Previous Practitioners
Previous choice of birth place
Home (describe method)
Name of hospital
Who attended your births?
Please check all that pertain to your previous births Vaginal delivery C-section Back labour Epidural Episiotomy Induction Forceps Vacuum Posterior presentation Breech baby presentation Other
If other, please describe
Previous birthing positions Lithotomy (on back with feet up) Squatting On all fours Side Lying Birth stool Birthing water tub Other
Did your babies experience any of the following? Premature birth Low APGAR Scores Low Birth Weight Failure to Thrive Colic Breathing Difficulties Allergies Breastfeeding Difficulties Formula-fed Developmental Delays Other