Client Information Form

Pregnant Parent's Name*
First Last
Pregnant Parent's Date of Birth*
MM slash DD slash YYYY
Baby’s name (if decided) or nicknames:*
Baby's Due Date*
MM slash DD slash YYYY
Baby's Sex*
Please list the total number of previous pregnancies.*
Please list the total number of live births.*
If you have other children, please provide names, ages, and a brief description of the birth experience.*
If you have any fur children (pets), please list type of animal(s), name(s), and their behavior with guests:*
Address*
Pregnant Parent's Primary Phone*
Pregnant Parent's Secondary Phone
Pregnant Parent's Email*
Suport Partner's Name
First Last
Support Partner's Relation to the Pregnant Parent*
Support Partner's Phone
Support Partner's Email

Kindly list current occupations or interests of the pregnant parent and support partner.*
Do you have a religious affiliation or any special customs you’d like me to know about?*

OB Physician/Midwife*
First Last
OB Physician/Midwife's Phone*
Where do you plan to give birth? If at a hospital or birth center, have you toured this location?*
Labor and Delivery/Birth Center phone*
Do you plan on having anyone else support you during labor? If so, please list name(s), relation, and phone number(s).
Please list all allergies, RH blood type, and any complications during your pregnancy (diabetes, GBS status, etc.):*
Have you ever experienced any neck, back, or pelvic issues (trauma, fall, car accident, broken tail bone, etc.)?*
Please list any cervical surgeries or any surgery that might have resulted in cervical scar tissue (cesarean birth, cryosurgery, LLETZ, LEEP, etc.):*
Please list any medications, herbs, homeopathy, or vitamins you are taking.*
Are you utilizing any therapies (chiropractor, acupuncture, massage, aromatherapy, etc)?*

Have you participated in childbirth education, pregnancy, or postpartum related classes?*
Please tell me about any parent or baby related books you're reading.*
Any past or present circumstances that may affect this birth or may concern you?
Please note or add any information you would be interested in learning more about.*
Ex. how to create a birth plan, induction procedures, pros and cons of medication, eating in labor, laboring in water, breastfeeding, etc.
Specific requests / photograph or video / desires / fears for birth?
List everything you can think of! For example... “For me, the best approach to pain relief and coping techniques are …”

What kind of encouragement or motivation do you best respond to?
How strongly would you like me to encourage you to achieve the goals we will talk about?*
“My top three priorities for this birth are …”*
“The following is also very important to me …”

What role do you see your partner playing during labor? Is there anything you really want your partner to do? Anything you don’t want your partner to do or see?*
What is your planned method of infant feeding, formula, or breastmilk?*
If you have breastfed before? Please describe your previous experience(s). If this is your first pregnancy, what are your thoughts about breastfeeding?*
Are there any concerns about pregnancy or postpartum period for you and your partner?*
Who will take care of the pregnant parent after the birth?*
Have you considered a postpartum doula?*
Would you like to reserve my placenta encapsulation services for your birth? If yes, please specify capsules, tincture, and/or whipped body butter.*
How would you rate your communication with your care provider?*