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Booking Questionaire
In order to better support you and perhaps have you think a little deeper about your upcoming birth, here is a questionnaire that you can choose to answer as many of the questions as you feel comfortable to share.
It is beneficial for all attending the birth to have a think about these areas to better be present to the story unfolding with this baby. I look forward to your answers. Jo
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Indicates required field
Name
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First
Last
Phone Number
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Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Date of Birth / Age
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Occupation
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Referred by:
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Last Menstrual Period
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Length of Period
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Length of cycle
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Baby's guess due date
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Height
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Weight
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Blood Group
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GP Details
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Birthing History
How did you feel when you first found out you were pregnant? How do you feel now?
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Previous Conception/Loss/Birthing History
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Previous Pregnancy & Postnatal History
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How did you feel about your menarche? What is your relationship with your bleeding cycle?
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If you know, how you were born? What is your birth story? And that of any older siblings.
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Is there anything in your history you feel I should know?
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relationship
How did you and your birthing partner meet?
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How would you describe your relationship with your birthing partner?
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Intentions
Any Previous or planned Childbirth Education?
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What is important to you about how you birth this baby
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Share any Moments of challenge in your life
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Describe any interactions with the hospital system
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How would you best like to be supported by me?
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Is there anything else you would like to share?
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Personal Medical History
Current General Health
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Allergies ADRs
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Previous Hospital Treatments/Operations
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Smoking, alcohol & social drug history
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Check all conditions that are/have related to you
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Rheumatic fever
Hypertension
Hepatitis
Jaundice
Thromboembolism
Renal disease
Diabetes
Cystitis
Respiratory disease
Asthma / hay fever
TB
Blood transfusion
Migraines
Thyroid Issues
Epilepsy
German measles
STDs
Herpes
Thrush
Eczema
Psoriasis
Mental & Emotional Health
Depression / Anxiety / Sexual & Physical abuse
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Emotional Health during pregnancy
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Partner's emotional & mental health
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Family Medical History
Current health & relationship with parents
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Medical Conditions - Mother
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Medical Conditions - Father
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Medical Conditions - Siblings & their kids
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