Better Birth Forms

Birth Intake

Due Date:
Home phone:
Cell phone:
Work phone:
Partner's phone:
Do you have other children? Their names & ages? Will they attend the birth?
Do you have childcare arrangements for the birth?
Does anyone else live in your household? Names and relations?
Name of OB or midwife:
Their phone:
Planned birth location:
Back up hospital:
(if above is a birth center)
Have you toured &
registered at the hospital?
No Yes
Your Pediatrician:
Have you taken a childbirth preparation course? Which & when?
Have you taken a breastfeeding class? Which & when?
Have you taken any other prenatal or newborn classes (massage, yoga, etc?)
Have you seen any other care provider? (ie, acupuncturist, chiropractor, therapist, etc?)
Do you have any questions or concerns about the care you are receiving?
How is your health?
Do you have any allergies?
Do you have a special diet? (allergies, vegan, etc?)
Do you take any supplements, vitamins, or medications?
Do you drink alcohol? No Yes
Do you exercise? No Yes
Are you receiving care for any other physical or mental health issues?
Is there anything else you want to share about your physical or emotional health related to your pregnancy and birth that will help me better serve you?
Do you or your partner have friends or family involved in your birth plans?
Is there any information about friends or family involved in the birth that you would like me to be aware of?
Have you been pregnant before? No Yes
Have you given birth before? No Yes
How many children do you have?
Do you plan to breastfeed? No Yes
Have you breastfed before? No Yes
Do you have any concerns about breastfeeding?
Have you or any family members experienced postpartum depression before?
Have you experienced any complications with this pregnancy?
Are you experiencing any discomforts?
Do you have a birth plan written? Have you reviewed it with your caregiver? If you have a plan, please email me a copy. I can also provide materials to help you in exploring your options and creating a birth plan.
Do you have any emotional or physical aspects of preparation for birth that you would like some special information or support with?
Because of the unique challenges of birth, it's possible that a prior trauma or violent incident can impact your birth experience. By being aware of this I can better serve you, and any information you choose to share with me will be kept absolutely confidential. Due to the sensitive nature of this topic we can discuss this during our visit, or if you prefer you may share any concerns below.
Is there anything I should be aware of as your doula in order to provide you the best possible care? Do you have any special concerns or questions you would like us to discuss during our visit?
  Heidi Thaden-Pierce is collecting this information as it pertains to your case only. She will never divulge your private information to anyone without your express consent.