Labor Support Intake Form

I have created this questionnaire as a tool to get you thinking about your dreams, concerns, preferences, fears, thoughts and emotions surrounding the upcoming birth of your child. Feel free to write as much or as little as you feel comfortable sharing. Your answers are completely confidential. Thanks! 

I. GENERAL INFO
Mother's name *
Mother's name
Date of birth *
Date of birth
Mobile phone *
Mobile phone
Partner's name
Partner's name
Partner's mobile phone
Partner's mobile phone
Estimated due date *
Estimated due date
Home address *
Home address
If yes, what was your impression?
Please include the names of all doctors and /or midwives in the practice.
II. HEALTH HISTORY
If yes, please explain.
If yes, please provide name of medication.
If yes, please explain.
If yes, please explain.
If yes, please explain.
If yes, please explain.
If yes, please explain.
If yes, please explain.
If yes, please explain.
If yes, what are their names and ages?
Do you have an opportunity to rest or nap each day?
If yes, what kind and how many days/week?
If yes, how much?
If yes, how many per day?
Does your partner smoke?
III. YOUR PREGNANCY
If yes, was it spontaneous, IUI or IVF?
If yes, please explain.
If yes, please explain.
What is your Group B Strep (GBS) status?
If yes, please explain.
If yes, when and what was your impression?
IV. LABOR AND BIRTH
Which comfort measures do you anticipate using to work with your contractions?
If yes, please describe.
Have you shared your birth preferences with your care provider(s)?
If yes, what are they?
Are you planning on having photos/video taken?
V. BREASTFEEDING AND NEWBORN CARE
Are you planning on breastfeeding?
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