Name *

First Name

Last Name

Name

Partner/Support Person's Name

First Name

Last Name

Any medical conditions developed DURING pregnancy

None

Gestational Diabetes

Group Strep B

Severe Insomnia

Anxiety

Depression

Hyperemesis Gravidarum (severe morning sickness)

Anemia

Heartburn

Headaches

Pica

Back Injury/Pain

Preeclampsia

Please check any topics you would like to discuss further:

Ways labor can begin

Early labor signs and signals

Stages of labor

Timing and contractions

Natural comfort strategies/pain management

Breathing techniques

Positions for labor

Unmedicated/Medicated labor and birth

Unmedicated/Medicated Inductions

General Triage procedures

Common medical procedures in labor

Pain medications/medical interventions in labor

Positions for pushing

Assisted vaginal delivery

Cesarean delivery

VBAC

Post birth procedures

Newborn procedures

Postpartum support planning

Postpartum mood and anxiety disorder

Have you made a birth plan? (if not we can do this together or review what you have)

Yes

No

Have you shared your birth preferences with your care providers?

Yes

No