I can’t wait to work together Congratulations on your pregnancy! I am honored to take this journey with you and look forward to learning more about you and your desired birth experience. Completing this form will help to determine how I can serve you best. Over time, some (or many!) of these answers may change, so simply input based on your current knowledge and preferences. We will navigate the rest as your pregnancy progresses and please let me know if you have any questions. Name * First Name Last Name Email * Phone (###) ### #### Address * Partner/Support Person Name and Phone # PS This form has a "you" focus. I want to know more about you and your personal experience. Going forward, our relationship will encompass everyone involved in this journey with you - partners, other children, close friends, etc - and I can't wait to hear how they're feeling and how they can be supported as well. Care Provider Details OBGYN/Midwife name Where do you plan on delivering? At home St Charles Family Birthing Center Bend Birth Center Not sure yet Have you toured the delivery location? Yes No I plan to Do you have health insurance? Yes, OHP Yes, not OHP No Did you choose your provider specifically? Yes No Are you comfortable with your provider? Yes No (we will talk more about this) Current Pregnancy Details Estimated Due Date Baby Gender Boy Girl It's a surprise! Do you mind telling me a little about your journey to becoming pregnant? What are you most looking forward to, or what's the light at the end of the tunnel when things are feeling tough with pregnancy or anxiety about what's to come? Past Pregnancy Details What number pregnancy is this for you?* Number of previous births? Were any of those babies born pre-term (24-37 weeks)? Have you experienced any of the following types of births? Check all that apply Vaginal Cesarean VBAC Elective Induction Induction for Medical Reasons Hospital Birth Home Birth What are the names and genders of your other children? *It's helpful for any care provider supporting you, including myself, to know of any pregnancies that didn't make it to term or if the journey to parenthood hasn't been straightforward. No need to share any of the details in this form, but would love to embrace that in our future conversations. Medical Do you currently have any pregnancy-related health conditions? * Have you had any pregnancy or birth-related health conditions in the past? Do you have, or have you had, any conditions, diagnoses, or operations that you've been told might affect your pregnancy and delivery? Birth Preparation PS There are no wrong answers Have you taken, or do you plan on taking, any childbirth education classes? If yes, please share the name below Are you, or your partner/support person, reading any books to prepare for labor or postpartum? If so, I'd love to know which ones Birth Plan Do you have a birth plan? If not, we will create one together. Yes No I have a rough draft What is your birth vision? If all goes perfectly, what would that look like for you? How do you envision a doula's support being most helpful? Do you envision yourself laboring unmedicated? Yes No Who all (partner, friends, or family) will be in the room and how do you envision their role? Do you have any fears or concerns regarding this birth? Are there any religious or cultural beliefs I should be aware of regarding your birth? In previously painful or emotionally intense situations, what has been most comforting? Postpartum Preferred Feeding Method You can choose more than one Breast/Chestfeeding Formula Donor Milk Not sure yet Do you have any concerns about feeding baby? Do you have any postpartum concerns? What kind of postpartum support will you have? Pregnancy, birth and postpartum can sometimes bring emotions or past experiences to the surface, even if they're unrelated to this journey. Is there anything you'd like me to be aware of as we prepare for labor and delivery? This could include past trauma, emotional challenges, or personal experiences. We can discuss this during one of our prenatal visits, or whenever you are comfortable, and you can let me know what is most helpful - to simply listen and hold space or advocate for accommodations to ensure a safe and comfortable experience. Is this a topic I should follow up on? Yes Nothing comes to mind Do you have any questions are anything else you'd like to share with me? Thank you! I will read over your answers shortly and be back in touch.