Name
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First Name
Last Name
Preferred Name, Pronouns
Email
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Phone
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Partner/Spouse Name
First Name
Last Name
Partner/Spouse Preferred Name, Pronouns
Partner/Spouse Email
Partner/Spouse Phone
(###)
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Address
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Please include info on where I should park when visiting you.
Estimated Due Date
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MM
DD
YYYY
Primary Midwife/OBGYN & Planned Delivery Location
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Regarding preparedness for birth and postpartum, what do you currently feel confident and knowledgeable about?
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What would you like to know more about?
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What are you hoping for your labor/birth? Think about how you want to feel, how you want to manage pain, what types of support you anticipate needing.
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Is this your first pregnancy? If not, I'd love to know more about your prior pregnancy experience(s).
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Please share what you feel comfortable sharing at this time. It's ok if you would prefer to share later, in person.
Do you have any specific concerns or worries regarding this birth?
Have you experienced any complications with this pregnancy so far? Do you have any restrictions or medications related to this pregnancy?
Is there anything in your personal history that might make it hard for you to cope with the experience of labor and/or nursing? If so, please explain
What does your current prenatal diet consist of?
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What is your planned method of feeding? (breast/chest feeding, pumping, formula, etc.)?
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What are some of your biggest concerns about the postpartum period?
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Are you interested in using plants/herbs to support postpartum recovery? (i.e. herbal sitz baths, herbal teas, steaming, etc.)
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How would you describe your and your partner/spouse's personalities?
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Are there any identities that are important to you and/or your partner/spouse? How do you expect these identities to play a role in your labor/birth and postpartum experience?
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Where do you carry tension in your body? What do you find helpful for that?
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Are you seeing any wellness practitioners for regular care? (chiropractor, acupuncturist, naturopathic doctor, etc)
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What is your current stress level? In what ways do you deal with stress in your life? What helps you to feel calm and grounded?
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What does your family and support system look like?
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Any allergies or medical conditions I should know about?
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Do you prefer printed out copies of materials or would you like materials sent to you digitally?
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Is there anything else you would like me to know?
How did you find me? If a referral, who referred you to me? I'd love to thank them.
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