Previous Birth Form

1

If you have had multiple births please answer the questions pertaining to each birth and label them numerically. (Ex: Birth 1, Birth 2, etc)

2

Name* This field is required.

First Name

Last Name

3

Vaginal Births* This field is required.

4

Cesarean Births* This field is required.

5

VBAC Births* This field is required.

6

Where did you birth and who was your provider?* This field is required.

7

Did labor start naturally or were you induced; how many weeks gestation?* This field is required.

Remember to label for each birth

8

If labor was induced, what type of induction and why?* This field is required.

Write N/A where ever needed for following questions.

9

Did your water break on its own or with medical help? * This field is required.

10

Did you have an epidural? If so, was it a positive experience? * This field is required.

11

Did you have any other pain medications, if so what?* This field is required.

12

How long were you in labor? * This field is required.

13

If vaginal birth, how long were you pushing?* This field is required.

14

Did you have an episiotomy, natural tear, or need stitches?* This field is required.

15

If cesarean birth, why did you have one?* This field is required.

16

What was baby's birth weight?

17

Any complications for your birth/s?* This field is required.

18

How was your healing following your birth/s?* This field is required.

19

What was the best part of your birth/s? * This field is required.

20

What is something you would have changed?* This field is required.

21

Did you breastfeed? If so, how long? * This field is required.

22

What are your plans for your children for this upcoming birth? * This field is required.

23

What are the names and ages of your child/children?* This field is required.

24

Additional Comments

25