Pregnancy & Health History Questionnaire


 

We appreciate you completing the following form in order to best support you in your pregnancy journey. We have found clients appreciate the opportunity to share and acknowledge some of these experiences without having to discuss them at length. Please do not hesitate to reach out to us if you would prefer to have these conversations in person. We appreciate that you are willing to entrust us with this information and we will maintain complete confidentiality and discretion. 

 
Name *
Name
Estimated Due Date *
Estimated Due Date
Describe your overall health pre-pregnancy.
List any chronic or lingering illnesses or conditions of which you feel we should be aware.
Do you have any allergies or sensitivities?
Are there any medications you may need to be reminded to take during labor?
Do you have any mental or emotional health concerns you care to disclose? If so, how can we best support you through your pregnancy and labor?
Have you experienced any trauma you feel may affect your birth experience (i.e. loss of a loved one, victim of a crime or abuse, previous injury or hospitalization). If yes, please explain how you feel we can best support your birth experience.
Please list your previous pregnancies including any childbearing losses you would like us to be aware of such as miscarriage, abortion, stillbirth or adoptions.
Are there any issues or concerns regarding this pregnancy that you feel we should be made aware of?