Private Childbirth Class registration Form

Home Address

Estimated Due Date

Month Day Year Date Picker Icon
Birth Place
Provider
# Pregnancy
# of Children
Mother
Have you taken childbirth classes in the past?

Yes No
In what ways have you prepared for childbirth during this pregnancy? (Books, Movies, Websites, Classes)
What areas of pregnancy, childbirth and postpartum do you hope to learn about in class?
What are your plans for coping and comfort during labor and birth?
How do you see your partner's role during labor and birth?
How has your pregnancy been so far?
Do you exercise regularly?

Yes No Sometimes
How would you describe your diet?
Do you plan to breastfeed?

Yes No Maybe
Any other information of concerns?
Partner
Have you taken any childbirth classes in the past?

Yes No
In what ways have you prepared for childbirth during this pregnancy? (Books, Movies, Websites, Classes)
What areas of pregnancy, childbirth and postpartum do you hope to learn about in class?
What is your understanding of her wishes for coping and comfort during labor and birth?
How do you see your role during labor and birth?
Do you exercise regularly?

Yes No Sometimes
How would you describe your diet?
Would you like her to breastfeed?

Yes No
Any other information or concerns?
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Childbirth Class Registration Form