CLIENT QUESTIONNAIRE Name * First Name Last Name Due Date * MM DD YYYY Care Provider * Hope to deliver at * Home Hospital Birthing Center Unsure How is your usual period cycle? * How has your elimination been during pregnancy? * Are you allergic to anything? * Have you had any medical issues with your pregnancy? * Any medical issues, illness, or disability that could impact your labor/the way I can support you? * List any prenatal tests done, with results: How much sleep are you getting? * Are you feeling rested or restless? * How do you manifest body tension? * (migraines, shoulder pain, etc.) In a (physically and/or emotionally) painful situation, how do you comfort yourself? * What is your preference for use of sensation management? * Do you have birth preferences? * Do you have a plan for your birthing center or hospital stay? * How do you feel your pregnancy is going? * What are the most stressful aspects of your life right now? * Who, if anyone, do you turn to for support? * Do you have anyone who is able to support you when your baby arrives? * Have you experienced any significant losses/traumas that you would like to share? * Previous Birth(s) Information * Have you given birth before? If answer is no, skip the next few questions Yes No If yes, how many previous births? Did you like your birth(s)? What was the best thing about the birth experience(s)? What would you like to repeat or avoid this time around? Anything additional that you would like to share that would be helpful for me to know? Anticipated Birth Information * Who, if anyone, would you like to be present at this birth? Imagine your ideal birth... what are its most important aspects for your happiness, comfort, and peace of mind? * What are your greatest fears about birth? * In the event of a Caesarean section, what things would be most important to you? * Reflect on a time when you felt especially calm....What were the circumstances? * Reflect on a time when you were especially powerful....What were the circumstances? * What coping techniques for labor do you plan to use? * (water, massage, visualization, pain medication, etc.) How do you envision me being most helpful to you during your birth? * What are your hopes for infant feeding? * Will someone be with you to take care of you in the postpartum period? * Are you interested in placenta encapsulation? * Yes No Unsure Thank you!
