Private Childbirth Class registration Form

Childbirth Class Registration Form
Mother's Name

First NameLast Name
Mother's Phone

Area CodePhone Number
Mother's E-mail
Partner's Name

First NameLast Name
Partner's Phone

Area CodePhone Number
Partner's Email
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Estimated Due Date

MonthDayYear
Birth Place
Provider
# Pregnancy
# of Children
Mother
Have you taken childbirth classes in the past?

YesNo
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?

YesNoSometimes
How would you describe your diet?
Do you plan to breastfeed?

YesNoMaybe
Any other information of concerns?
Partner
Have you taken any childbirth classes in the past?

YesNo
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?

YesNoSometimes
How would you describe your diet?
Would you like her to breastfeed?

YesNo
Any other information or concerns?
Should be Empty:

Childbirth Class Registration Form