Birth Mom’s Questionnaire – Birth Works
We will have the opportunity to explore many issues in depth during the coming weeks. This questionnaire is intended as an overview to help me know who is in this class, and the issues and needs I should plan to address. All information is confidential!
Name:______Age:______
If currently pregnant, due date:
Was this a planned pregnancy?
If you are employed, what do you do?
Do you intend to be employed after the baby is born?
What is your marital/relationship status? How Long?
What are your hopes for this birth?
What are your concerns or fears about this birth?
Any physical problems during this pregnancy?
Are you generally healthy or have you often had illnesses or injuries?
If you have had any miscarriages, abortions, stillbirths or other child death, or have released a child for adoption, please give the year(s) of each:
If you have other children, please give names and ages of each and if they live with you or elsewhere.
Do you plan to breastfeed?
Did your mother or anyone in your family breastfeed?
At this point, who is your midwife and/or doctor, and where do you plan to give birth?
Do you exercise? If yes, please describe.
How do you feel about your eating habits and nutritional status?
What reading have you done about pregnancy and birth?
Have you taken or heard about any other childbirth preparation courses? What was your reaction?
Why did you choose Birth Works?
What do you want from this course?
What specific issues would you like to have discussed?
Briefly describe any previous childbirth experiences:
How has this pregnancy or previous children affected your relationship with your partner?