Medical and Personal History
Below is a sample of The Medical and Personal History Form that I ask clients to complete before our first prenatal visit.
Mother's Name:
Date of Birth:
Address:
City, State, ZIP:
Home Phone:
Cell Phone:
Your Weight at Your birth:
Your Occupation:
Usual Weight (non-pregnant):
Father's Name:
Father’s Weight at Birth:
Partner’s Cell Phone:
Occupation:
Doctor/Midwife Name:
Phone:
Office Address:
HOSPITAL/BIRTH FACILITY
Where do you plan to have this birth?:
Have you visited the Maternity Wing of this place before?:
OTHER
Due Date:
Sex of Baby (if known):
Name of Baby (if known):
Have you taken any childbirth preparation classes?:
If yes, location and instructor:
How else have you prepared for this birth? (books, videos, etc.):
To what extent do you drink alcohol?:
Do you smoke cigarettes?:
Does your partner?:
If yes, when and how much do you or your partner smoke?:
If you used to smoke, when did you quit?:
How much do you sleep at night?:
Do you have an opportunity for rest periods or a nap each day?:
In general, how have had you felt about this pregnancy?:
Please list the people you plan to invite to your birth:
Do you plan to breastfeed this baby?:
IMPORTANT INFORMATION THAT CAN GREATLY AFFECT YOUR LABOR
Do you have herpes?:
Have you tested positive for Group B Strep?:
Have you ever been sexually or physically abused? (you may respond verbally if you like):
No. of pregnancies (Gravida):
No. of Births(Para):
Abortions:
Miscarriages:
What else would you like me to know about your history, hopes, dreams, fears, strengths, limitations?:
IF YOU HAVE GIVEN BIRTH BEFORE, PLEASE ANSWER THE FOLLOWING:
How much did your babies weigh?:
Were your babies born early, on time or late?:
Did you breastfeed?:
For how long?:
Older Child(rens) Name(s)_:
Age(s):
For each of your births, please answer the following below:
How did your labor begin? How long were you in labor? Did you have any complications during the labor or after the birth?
THE FOLLOWING QUESTIONS ARE USED FOR CREATING PERSONLIZED CARE
Please complete the following sentences:
Childbirth is:
A Laboring woman:
Favorite Bible Verses or Quotes:
Favorite Color:
Favorite Band/Music/Songs:
Favorite Scent:
Favorite Food:
Favorite Snack:
Favorite Fruit:
If you could “plan” out your ideal birth, describe it here:
Other comments, thoughts, or other things that you know will help you during labor:
