Client Information Form

Name(required)

Partner's Name (required)

Email(required)

Phone Numbers (of both you and your partner(required)

Address

Due Date

Number of previous pregnancies:(required)

Number of previous miscarriages:

Number of previous abortions:

Were any of pregnancies premature births (prior to 36 wks)?(required)

YES NO

Have you every had a cesarean section?(required)

YES NO

If yes, describe the circumstances:

Have you ever had a VBAC?

YES NO

Care Provider Name:(required)

I plan to give birth:(required)

If hospital or birth center, which one:(required)

Do you currently have, or have you had a history of any of the following prenatal conditions:

Group B Strep Pre-eclampsia Gestational Diabetes IUGR multiples pregnancy Preterm Labor AIDS Herpes other STDs

Any other health concerns I should be aware of?

What are your feelings about labor and delivery?

What is your biggest fear about labor and delivery?

If you could deliver your baby in any setting, what would that be? What smells or sounds would surround you?

Is there anything else you would like us to know about you?

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