Please fill out this medical and personal history very carefully. When we meet again we will go over this history together and discuss your questions. Leave blank any technical terms or questions with which you are not familiar or any questions you prefer to answer in person.
Mother:
Name _____________________________________ Date of Birth _______________Height
Address _____________________________________ City________________ Zip______________
Home Phone____________________________ Cell Phone ______________________
Email Address_________________________________________________________
Your Cell Partner’s Cell _________________________________ Alternate Contact Number _________________
Usual Weight (Non-Pregnant)_______________ Your Weight at Your Birth______________
Occupation______________________________________________________________________________
Partner:
Name ______________________________________ Baby’s Father’s Weight at His Birth______________
Occupation ____________________________________________________________________________
Doctor:
Name_________________________________________ Phone __________________________
Office Address _______________________________________________________________________
Hospital/Birth Facility:
Where do you plan to have this birth?______________________________________________________
Other: _____________________________________________________________________________
Due Date_______________ Sex of Baby (if known) ___________Name of baby (if known) ___________________
Have you taken any childbirth preparation classes? Yes / No
If yes, location and instructor __________________________________________________________________
How else have you prepared for this birth (books, videos, etc.)_________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
What do you know about your mother’s labors? _____________________________________________________
_________________________________________________________________________________________
Were they consistently fast or prolonged? ________________________________________________________
_________________________________________________________________________________________
Were babies consistently late or early?____________________________________________________________
_________________________________________________________________________________________
To what extent do you drink alcohol? ____________________________________________________________
Do you smoke cigarettes? Yes / No Does your partner? Yes / No
If Yes, indicate when and how much: _____________________________________________________
If you used to smoke, when did you quit? _____________________________________________________
How much do you usually sleep each night? _____________________________________________________
Do you have an opportunity for rest periods or a nap each day? Yes / No
Do you sleep well? __________________________________________________________________________
In general, how have you felt this pregnancy? _____________________________________________________
________________________________________________________________________________________
Do you plan to breastfeed this baby? Yes / No
The Following Can Greatly Affect Your Labor:
Do you have herpes? Yes / No
Have you tested positive for Group B Strep? Yes / No
Have you ever been sexually or physically abused? (you may respond verbally if you like) __________________
________________________________________________________________________________________
________________________________________________________________________________________
What else would you like me to know about your history, hopes, dreams, fears, strengths or limitations?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
No. of pregnancies (Gravida) _______ No. of births (Para) ______ Abortions ______Miscarriages _______
If You’ve Given Birth Before, Please Answer The Following:
How much did each of your babies weigh? ______________________________________________________
Were your babies born early, on time, or late? ____________________________________________________
Did you breastfeed? Yes / No For how long? _____________________________________________________
How long were you in labor for each of your babies? ________________________________________________
How did your labor(s) begin? ________________________________________________________________
Did you have any complications during the labor(s) or after the birth(s)? ________________________________
_____________________________________________________________________________________
Older children(s) name(s) and Age(s) __________________________________________________________
_____________________________________________________________________________________
