top of page

Introductory Questionnaire

Thank you for taking a moment to let me know a little bit about you.


Email Address*



Estimatted Due Date*

Birth Place*

Partner's Name


Name of Care Giver*

If a home or birth center birth, do you have a planned hospital back up?*

Have you taken a hospital tour?*

Have you registered at the hospital?*

What other health care providers do you see?

Have you taken any childbirth classes?*

Have you taken any breastfeeding classes?*

What other prenatal or parenting classes have you taken?

Number of previous pregnancies*

Number of births*

Where were your previous births?*

Have there been any complications with this or any past pregnancies?*

Who will be attending your birth?

What do you see as my roll in serving you?

Tell me a little about you and your family.

bottom of page