Birth Questionnaire
Due Date
Hospital
Doctor/Midwife/Practice Name
Family Information
Mother's Name
Mother's Birthdate
Street Address
Apt.
City
State
Home Phone
Cell Phone
Work Phone
Home E-mail
Work E-mail
Mom's Occupation
Still Working?
What are your plans after the baby is born? (i.e.  how long will your maternity leave be or will you be a stay at home mother?)
Partners Name
Partner's Occupation
Your other children:
(names and ages)
Childbirth Education
Have you taken any childbirth classes? (Lamaze, Bradley, Birthing from Within or other)?  If so which one(s)?
Have you read any books on the topic of Labor and Childbirth?  If so, which ones?
If yes to either of the above how did you like them?  Did they help you?  Do you have any unanswered questions about the
information they gave you?
Previous Births
How many previous births have you had?
Did you have any complications during pregnancy?
If yes, please explain:
Were the births vaginal or cesarean birth?
Full Term or Pre-term?
Baby's Birth Weights?
Were there complications with your labor?
If so, please explain:
Did your baby need any special care after he/she was born?
If so please explain:
Did you breastfeed or bottlefeed?
Did you have any postpartum depression after any of your other children?
If how do you plan on getting help for this after this pregnancy?
What would you say was positive about your past birth experiences?
What would you say was negative about your past birth experiences?
Current Pregnancy
Tell me about this pregnancy:
Was this planned or a surprise?
Are you excited and happy about this baby? Explain
Do you have a good support system at home?  (husband or other)  Explain
Are you having a boy or a girl?
Tell me about your pregnancy.  How has it been for you so far, emotionally and physically?
Have you had any complications during your pregnancy?
If so please explain:
Are you planning a vaginal or Cesarean Birth?
If Cesarean Birth what are your reasons?
What kind of medical care provider will be handling your birth?
Who will be present in your labor and delivery room?
Who will be coming to the hospital to wait during your labor?
Why did you decide to contact a doula?
What do you expect from your doula and how can she help improve your past birth experiences?
What role will your partner be taking during labor and birth?
Do you want your partner to be primary, secondary, or equal support with your doua?  Explain:
Infant Care Questions
Will you breast feed or formula feed your baby?
Would you like assistance with breastfeeding?
Do you have any questions specifically about that we should discuss when I visit:
Baby Care
Mother/Infant Bonding
Birth Plan
 Nutrition and Exercise
Partner Support
Breastfeeding
Breathing/Relaxation
Patient Rights and Responsibilities
Cesarean Birth
 Physical Recovery
Positions for Labor
Circumcision/Immunizations
Preparing for New Family
Comfort Measures (non-drug)
Role of the Doula
Communication with Care Provider
Other
Community Resources
Emotional Recovery
Epidural/Pain Medication Protocol
Episiotomy