HeartRoots

Prenatal Questionnaire

 

 

About You

 

Name:                                                                 Todays date:                                   

 

Age:                      Date of birth:

 

Home address:                                                

 

Phone (home):                                                              Phone (cell):                                  

 

Email:                                                                          Occupation:

 

Partners name:                                               Age:                      Do you have any children:                            

 

Health Care Providers

 

Who is your primary care provider:                                             Is this the person who will attend your birth:

 

If not, what is the name of your OB or midwife:                                

 

Name of place where you will be giving birth:                                             Phone:                  

 

If a home birth, what is your backup hospital:                                              Phone:   

 

Have you/do you plan to take childbirth/breastfeeding classes:           If so, with whom:

 

Do you have any other health care providers not mentioned:

 

Support Information

 

 

Who will be attending your birth:                                 Plan of care for children during labor/birth:  

 

What are your primary reasons for wanting a doula:

 

What are your expectations of your doula:

 

Do you have any fears/concerns about pregnancy:

 

Do you have any fears/concerns about birth or postpartum:

 

Health History

 

General state of health:

 

Pregnancy Health:

 

Any special Concerns regarding your health:

 

Allergies (drugs, food, latex): 

 

Diet:                                              Vitamins/supplements/prescriptions:

 

Do you drink/smoke/ingest drugs:                                    Quantity/Frequency:

 

Do you exercise/Frequency:                                           Do you/have you had any STD's/STI's:

 

Any major surgeries, injuries, hospitalizations:

 

Do you have a history of emotional/psychological problems:

 

Your Pregnancy

 

In pre-pregnancy do you suffer from PMS:            

 

If so, what are your symptoms:                                        Coping techniques:

 

Is this a planned Pregnancy:                       How do feel now about it: 

 

What is your expected duedate:                               

 

Any previous pregnanies:                             Miscarriages:                                   Live births:     

 

Prior pregnancies:

 

       Date of birth    #Weeks at birth    Sex    Weight      Name/outcome      Labor length       Meds/intv/compl.

 

#1

 

#2

 

#3

 

#4

 

Pain management:                                                      Coping techniques:                         

 

Interventions (fetal monitering, induction, episiotomy, c-section etc.):

 

Have you breastfed before:                                Any problems:  


Have you ever had/are you concerned about having postpartum depression: 


Have you had/do you plan on having an ultrasound: 

 

Do you want to know the sex of your baby before birth:

 

Do you want your placenta encapsulated/would you like information about placenta encapsulation:

 

Your Birth

 

What is your vision for this birth:

 

 

 

Where in your body do you usually feel tension: 

 

How do you manifest tension (check all that apply):   difficulty breathing              sweating            panic            nausea        

moaning       grinding teeth          clenching fists          racing heart          anxiety         any other:     

 

How do you find comfort when experiencing stress/pain (check all that apply):  distraction         movement        silence      

 

turning inward     self-medicating behaviors (OTC meds etc.)        hot/cold packs       companionship       Any other:        

 

What is your plan for coping while in labor: 

 

How do you feel about medical procedures/intervention in birth:

 

How would you like your doula to respond if you are requesting pain medications:

 

 

 

Do you have a birth plan:                If not, would you like to learn more about them:

 

Do you want photography/video during your labor/birth:             If so, who will be taking pictures/video:     

 

Are there any areas of of your or your babies body you do not want photographed/filmed:

 

Are there any cultural/religious choices/preferences that may affect your labor/birth:

 

 

 

Do you have anything to add:

 

 

 

 

Thank you for taking the time to fill this out! 

 

(all responses are optional and will be kept strictly confidential)  

Sharon Jong, www.HeartRoots.ca 

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