Client Profile Name First Name Last Name Estimated Due Date * MM DD YYYY Baby gender? Girl Boy Unknown Surprise Email Address * Mother's Phone (###) ### #### Partner's Name First Name Last Name Partner's Phone (###) ### #### Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Chosen birth location for this birth * Home Goshen Hospital Memorial Hospital St. Joseph Regional Lakeland, St. Joseph MI Blessed Beginnings Birth Center Goshen Hospital Elkhart Hospital Birth Provider (Name of practice and/or OB/Midwife) Have you been happy with your current care? Do you feel confident in your understanding of your provider's birth philosophy, birth statistics and routine practices? Have taken a tour of your birth location? Yes No Planning on it Have you or are you planning on taking Childbirth Classes? Other providers you see (Chiro, Acupuncture, Homeopath, Massage therapist, yoga) General Health, pre-pregnancy and now (including anxiety, depression)? Allergies, sensitivities, diet restrictions Medications and Vitamins currently taking Exercise type and frequency? Do you smoke? History of personal trauma Previous Pregnancies and Births # of previous pregnancies Miscarriages Previous pregnancy complications/discomforts and treatment sought: Please list your previous births, week of gestation at birth, gender, name, weight, and brief labor details (labor length, interventions used, complications), emotional experience for you: Have you breastfed before? Problems? Have you had postpartum ocd/depression previously? Your Pregnancy General feelings about this pregnancy (Fears/Concerns?) Current pregnancy discomforts or complications and treatment sought: Your Birth What is your vision for this birth? Who will be present during your birth? What are your expectations of your doula? Where in your body do you usually feel and hold tension? How do you manifest tension physically? Difficulty breathing Sweating Panic attacks Nausea Grinding teeth Tense muscles Pain Anxiety Repetitive behavior (picking nails, cracking fingers etc) Other How do you comfort yourself when you experience stress or pain? Distraction Movement Silence Turning inward Self-medicating behavior (Food, alcohol etc) OTC drugs Hot/cold packs Showers/baths Companionship Other What is your plan for coping with labor? How do you feel about medical procedures/interventions during your labor and birth? How are you preparing mentally for this birth? How are you preparing physically for this birth? How are you preparing emotionally for this birth? Is there anything else that you would like me to know regarding your hopes, fears and vision for your birth? Thank you for taking the time to fill out this client profile. I look forward to learning more about you so that I can serve you best!
