Client's Name
Client's Age/Birth Date
Phone Number
Email Address
Client's Obstetrician or Physician, Including Practice, Address, and Phone Number
Infant's Name
Infant's Age/Birth Date
Infant's Primary Care Provider, Including Practice, Address, and Phone Number
How Many Pregnancies
How Many Births
Any Other Pregnancy Complications
Please List All Medications, Supplements, Herbs, Tinctures, Teas, Essential Oils, or Homeopathics Used During Pregnancy
Did Breast Size Change During Pregnancy. If So, When and How Much
Infant's Gestational Age at Birth
IV Fluids
None 1L 2L More Than 2L
Total Length of Labor
Total Length of Pushing Stage
Infant APGAR
Did You Have Immediate Skin-to-Skin Contact
Yes Brief Delay Delayed 30min-1hr Delayed 1-2hr Delayed More Than 2hr
When Did Infant First Latch
Immediately 0-30min 30min-1hr 1-2hr More Than 2hr
List Any Other Parent or Infant Complications
Medications Used During Birth and Postpartum Including Antibiotics
Describe Your Birth Experience and/or Provide any Missing Details
Did Infant Spend Any Time in NICU/How many Days
How Long After Birth Were You Discharged
Infant's Birth-Weight
Infant's Lowest Weight
All Other Available Weights and Dates
How Many Previous Surgical Births Have You Had
How Many Previous Vaginal Births Have You Had
Describe Previous Pregnancies and Births Including Complications
If you are human, leave this field blank.
Submit