CLIENT INFORMATION FORM
Person Giving Birth
Name
First Name
Last Name
Date Of Birth
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Month
-
Day
Year
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Phone Number
Please enter as xxx-xxx-xxxx
E-mail
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please provide directions to your home from the nearest interstate:
Other Children & Ages
Partner Information
Name
First Name
Last Name
Phone Number
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Area Code
Phone Number
E-mail
Health Care Provider Information
Name
First Name
Last Name
Practice Name
Select Type
Obstetrician (OB)
Certified Professional Midwife (CPM)
Certified Nurse Midwife (CNM)
Direct-Entry Midwife (DEM)
Family Practice (MD)
Birth Information
Delivery Location
Estimated Due Date (EDD)
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Month
-
Day
Year
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Childbirth Education Preparation
Birth Questions
List five adjectives that describe how you have felt about this birth so far.
List the people you plan to invite to your birth.
List any emotional, medical, or health issues that could interfere with or complicate the birth process.
If you have had any other birth experiences, miscarriages, or other pregnancy experiences, please share how they are affecting this pregnancy and plans for birth.
What else would you like me to know about your history, hopes, dreams, fears, strengths or limitations in regards to this birth?
If you could labor and deliver your baby anywhere in the world and in any setting, what would your fantasy birth be like?
What are your three most important desires for this birth?
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