Labor Support Intake Form

Please answer the questions below with as much detail as possible. Your answers are completely confidential. Thanks! 

I. GENERAL INFO
Mother's name *
Mother's name
Date of birth *
Date of birth
Estimated due date *
Estimated due date
Mobile phone *
Mobile phone
Partner's name
Partner's name
Partner's mobile phone
Partner's mobile phone
Home address *
Home address
If yes, what was your impression?
Please include the names of all doctors and /or midwives in the practice.
If yes, how much?
If yes, how many per day?
Does your partner smoke?
Do you have an opportunity to rest or nap each day?
If yes, what kind and how many days/week?
If yes, please explain.
If yes, please explain.
If yes, please explain.
If yes, please explain.
If yes, what are their names and ages?
II. PRENATAL
If yes, please explain.
If yes, was it spontaneous or IVF?
If yes, please explain.
If yes, please explain.
If yes, when and what was your impression?
If yes, when?
III. PREVIOUS BIRTH EXPERIENCES
If not applicable, please scroll down to Section IV (LABOR AND BIRTH).
If yes, how many weeks gestation? If no, how was labor induced and why?
If yes, on its own or with medical help?
If yes, with what?
If yes, what did you think of it?
If yes, which ones?
What kind of birth?
Did you have?
If yes, why?
If yes, how long?
IV. LABOR AND BIRTH
Have you shared your birth preferences with your care provider(s)?
If yes, what are they?
Which comfort measures do you anticipate using in labor?
Are you planning on having photos/video taken?
V. BREASTFEEDING AND NEWBORN CARE
Are you planning on breastfeeding?
If yes, please explain.
If yes, please explain.
Take a look at your nipples, do they appear to be?
If no, why not?
If yes, please explain.
If yes, please explain.
Do you have a pediatrician?
When I say painless, please understand, I don’t mean you will not feel anything. What you will feel is a lot of pressure; you will feel the might of creation move through you. Pain, however, is associated with something gone wrong. Childbirth is a lot of hard work, and the sensations that accompany it are very strong, but there is nothing wrong with labor. - Giuditta Tornetta