Fertility Love Thank you for taking the time to share this information with me. It will help me to meet you individual needs throughout our work together. Contact InformationYour Name First Last Partner Name First Last Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email PhonePartner / Other PhoneYour Birth Date Date Format: MM slash DD slash YYYY How did you hear about me?*Choose OneFacebookGoogle SearchInstagramOtherIf other, please describe:Health Care Provider InformationWho is your medical provider?Type of Provider Midwife Doctor Unassisted Other If other, please specify:Location Where You Plan To Give BirthHomeHospitalBirth CenterOtherIf other, please specify:If you are planning to deliver at a birth center or at home, please specify your backup hospital (name, city/state)General Health InformationDo you have any allergies I should be aware of? If yes, please describe:Have you had any recent illnesses, surgery, injuries or accidents that you wish to share with me? If yes, please describe:Do you currently take any prescription or non-prescription medications that you want me to be aware of? If yes, please describe:Have you had any periods of mental illness, depression, anxiety disorder or previous postpartum depression that you wish to share with me?Explain anything else you would like me to know about your health condition:Previous Pregnancy InformationHow many times have you been pregnant (including current pregnancy)How many times have you given birth?How many of your pregnancies have been carried to term (born after 37wks)?How many of your pregnancies were preterm (born between 24-37 weeks)?How many of your other births ended before 24 weeks?How long did your previous labor last?How many children do you have?Have you given birth to multiples?This is my first childYesNoHave you placed any children for adoption?This is my first childYesNoHave you adopted any children?YesNoWhich types of births have you experienced? (Select all that apply) This will be my first birth Vaginal C-section VBAC (Vaginal Birth After Cesarean) Elective Induction Induction for medical reasons Home Birth Hospital Birth Birth Center Have you had any of the following pregnancy-related health conditions in PAST pregnancies? Rh incompatibility Hyperemesis Gravidarum (excessive vomiting) Gestational Hypertension (high blood pressure during pregnancy) Pre-Eclampsia Preterm Labor Intrauterine Growth Restriction (IUGR) Low Birth Weight Macrosomia (large baby) Polyhydramnios Oligohydramnios Group B Strep Gestational Diabetes Placenta Previa Placental Abruption Vena Cava Compression Postpartum Hemorrhage Postpartum Depression Genetic Disorder None of the above Please tell me anything you would like me to know about your past pregnancies:Current Pregnancy InformationBaby's Due Date Date Format: MM slash DD slash YYYY Are you expecting multiples? (Twins, triplets, etc.)YesNoIf yes, how many?What type of birth are you planning?VaginalC-sectionVBACElective InductionInduction for Medical ReasonsHow do you plan to birth:Naturally (no pain meds)EpiduralOther pain medicationI don't knowPlease list any pregnancy related health conditions you've had in your current pregnancy:Birth WishesDescribe what your ideal birth would be:Do you think labor will hurt?YesNoNot SureAre you afraid of the pain?How do you ordinarily deal with pain? How do you see yourself coping during labor?Do you have any fears of this birth?Rate how much you would like or not like each of the following to occur during your childbirth experience.