Full Name
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First Name
Last Name
Preferred Pronouns
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Partner's Name (If Applicable)
Preferred Pronouns
Phone
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Partner's Phone (If Applicable)*
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Email(s)
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Home Address
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Where are you planning to give birth?
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Care Provider(s)
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Estimated Due Date
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Are there any special conditions pregnancy related or otherwise you'd like to disclose?
Have you had any past procedures that may have resulted in scar tissue on your cervix or uterus?
Do you have any allergies you’d like to disclose?
Have you received your glucose test results?
Have you received your Group Beta Strep test results?
Have you taken or do you plan on taking a Childbirth Education Course? If so, which one?
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Do you plan on keeping your placenta for encapsulation or otherwise? Would you like more information or contacts for placenta encapsulation?
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What are your experiences with birth or knowledge of birth up to this point?
Do you have any questions relating to childbirth education courses you’ve taken?
How do you envision your partner’s role during your labor?
How do you envision your doula’s role during your labor?
What are your experiences with birth or knowledge of birth up to this point?
How do you envision your role during your partner's labor? What are some of the ways you have supported them through challenges in the past that you think might be useful during labor?
How can I best support you in supporting your partner during their labor?
When you think of your partner's labor what excites you? What are your greatest fears or worries?
Are there any life experiences you feel may impact you or come up during your birth that you would like to share?
What have been your methods of coping with physical pain in the past? What about emotional pain?
How would you characterize your pain tolerance? Please be creative in your analysis!
Where do you carry tension in your body?
What coping techniques for labor are you familiar with or would like to use? (Water, visualization, etc.)
Consider your ideal birth. What are the most important aspects for your happiness, peace and comfort?
When you think of your birth, what excites you?
What are your greatest fears surrounding your labor & birth?
How are you planning to feed your baby? (Breast or chest feeding, bottle feeding, formula feeding, combination feeding, etc.)
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Consider your postpartum period; what is most important in your preparation in order to make this transition and time with your baby as smooth as possible?
How much time off work will you and your support person(s) have?
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What are your expectations (if any) for your postpartum period?
Will you have support from family, friends or professional help? Would you like more information about professional postpartum support?
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Is there anything else you would like to discuss or you feel is important to share while I support you during this transition?
Would you like any additional resource recommendations? Additional services I highly recommend include: Childbirth Education, Postpartum Doula Support, Acupuncture, Chiropractic, Lactation Support & Pelvic Floor Therapy.
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