Prenatal Questionnaire Name: * First Name Last Name Expected Due Date: * MM DD YYYY Provider Name + Title/Credentials * Name of Hospital / Birth Center / "At Home" * Any medical conditions, injuries, and/or joint complications that could affect birth or postpartum? Any mental health concerns? What part of labor are you most nervous for? What part of labor are you most excited for? How would you like me to support you during the labor process? Besides a healthy mom and healthy baby, what is your main goal for birth? How would you like your birth partner to be involved during your labor? I have a great relationship with my provider. Strongly Disagree Disagree Neutral Agree Strongly Agree How do you typically deal with discomfort or pain? What are some coping mechanisms that work for you in everyday life? Would you like any photography/videography at your labor? If so, what moments would you like to capture? Do you want to keep your placenta? Yes No Are you interested in a childbirth education class? Yes No What additional resources would you like for me to provide? Your responses have been submitted. Thank you!
