Memory Lane: Needs Assessment Form

EmailMeForm

Please fill out the following form to help me get to know you and your birth partner better before our interview. The information will assist me in knowing how to individualize your care and provide the best experience possible. (All the information is confidential.)

• Your Name *
• Your Occupation *
• Partner/Spouse's Name & Occupation
• Address *
  Street Address Address Line 2 City State / Province / Region Postal / Zip Code Antigua and Barbuda Aruba Bahamas Barbados Belize Canada Cook Islands Costa Rica Cuba Dominica Dominican Republic El Salvador Grenada Guatemala Haiti Honduras Jamaica Mexico Netherlands Antilles Nicaragua Panama Puerto Rico Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Trinidad and Tobago United States Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Faroe Islands Finland France Georgia Germany Greece Hungary Iceland Ireland Italy Latvia Liechtenstein Lithuania Luxembourg Macedonia Malta Moldova Monaco Montenegro Netherlands Norway Poland Portugal Romania San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Ukraine United Kingdom Vatican City Afghanistan Bahrain Bangladesh Bhutan Brunei Darussalam Myanmar Cambodia China East Timor Hong Kong India Indonesia Iran Iraq Israel Japan Jordan Kazakhstan North Korea South Korea Kuwait Kyrgyzstan Laos Lebanon Malaysia Maldives Mongolia Nepal Oman Pakistan Palestine Philippines Qatar Russia Saudi Arabia Singapore Sri Lanka Syria Taiwan Tajikistan Thailand Turkey Turkmenistan United Arab Emirates Uzbekistan Vietnam Yemen Australia Fiji Kiribati Marshall Islands Micronesia Nauru New Zealand Palau Papua New Guinea Samoa Solomon Islands Tonga Tuvalu Vanuatu Algeria Angola Benin Botswana Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Democratic Republic of the Congo Republic of the Congo Djibouti Egypt Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Gibraltar Guinea Guinea-Bissau Cote d'Ivoire Kenya Lesotho Liberia Libya Madagascar Malawi Mali Mauritania Mauritius Morocco Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Seychelles Sierra Leone Somalia South Africa Sudan Swaziland United Republic of Tanzania Togo Tunisia Uganda Zambia Zimbabwe Country
  
• Email *
• Cell Phone *
  ### - ### - ####
• Home Phone *
  ### - ### - ####
• Other Phone
  ### - ### - ####
• Best Time to Call *
• Doctor/Midwife *
• Place Where You Will Deliver *
• Due Date *
• Your Age *
• ABOUT YOUR BABY
• Baby's Name (if known)
• Baby's Gender (if known)
  Male Female
• Will this baby be circumcised?
  yes no
• Planned Method of Feeding
  Breast Bottle
• ABOUT YOUR HEALTH
• Have you ever been treated for infertility? If so, please describe the treatments or procedures and when they occurred.
• Please list any allergies or illnesses (chronic or otherwise) oof which I should be aware.
• Please list any prenatal testing and the results.
• Explain in detail any complications with this pregnancy and any restrictions placed on you by your caregiver, including listing any medications you are currently taking.
• Do you have any problems or former injuries in your hips, back, neck or knees that I should be made aware of? If yes, please explain.
• PREVIOUS BIRTH EXPERIENCE
• Have you had previous pregnancies? If so, how many?
• Have you had previous miscarriages? If so when?
• Have you had a still birth? If so when?
• Have you had any abortions? If so, when?
• Have you ever relinquished a baby for adoption? If so, when?
• Previous Birth Data: Please list the year, gender, child's name, weight, length, vaginal or cesarean birth for previous births.
• PREPARATION FOR BIRTH
• Have you had any childbirth education classes? Please explain the philosophy.
• Please list any other classes in which you are currently enrolled (breastfeeding, infant care, infant CPR, etc.)
• Who do you plan to have with you assisting with labor? Who will be in the room when you deliver?
• Are you preparing a birth plan? Do you need my assistance?
• What is your philosophy toward medical interventions including medications?
• Which comfort measures do you wish to try during labor? (Check all that apply.)
  Hot/Cold Therapy

  Massage

  Counterpressure

  Labor Tub

  Visualization

  Vocalization

  Shower

  Relaxation

  Breathing Patterns

  Birth Ball

  Distracting Activities

  Rocking Chair

  Epidural

  Narcotics

  Other
• What best suits your learning style?
  Visual (I learn by seeing)

  Auditory (I learn by hearing)

  Kinesthetic (I learn by doing)
• Would you describe yourself as an introvert or an extrovert? To answer this question, think about what you do at the end of a long, hard day. Do you need to be by yourself to recharge(introvert) or do you seek the company of others to recharge (extrovert)?
  introvert

  extrovert
• Optional: Do you have a history of emotional, physical or sexual abuse? If so, would you mind speaking about it in private? (Remember all information is kept strictly confidential.)
• In nervous or painful situations, how does your body typically react?

  Please rate the following; 1 being none and 5 being strongly reacts.
• Fast Heart Beat
• Chills
• Shaking
• Nausea
• Clenched Fists
• Vomiting
• Sweating
• Tapping Feet
• Restless Les
• Nail Biting
• Nervous Stomach
• Grinding Teeth (TMJ)
• In what areas of your body do you feel the most stress? (Circle all that apply.)
  Forehead

  Jaw

  Neck

  Shoulders

  Upper Back

  Lower Back

  Chest

  Arms

  Hands

  Legs
• List ways you typically cope with stress.
• EMOTIONAL NEEDS ASSESSMENT

  *BOTH YOU AND YOUR PARTNER SHOULD ANSWER THE FOLLOWING FOUR QUESTIONS.
• When thinking about the task ahead (labor and birth), what would you say are your strengths?
• When thining about the task ahead (labor and birth), what would you say are your weaknesses?
• What are your hopes for this birth, aside from "healthy baby and healthy mom"? If you could envision your "perfect" birth, what would it look like?
• What are your fears or concerns for this birth?
• CONTACT WITH YOUR DOULA
• Would you like for me to attend a prenatal doctor visit or childbirth class with you? If so, when?
• Please indicate how I can best assist you and your partner. Include any request for educational information (books, videos, internet resources), referrals, or additional postpartum care.
• Please give directions to your home using major streets, highways and landmarks. When your labor begins to progress I will meet you at your home until you feel its time to transfer to your birth location. (If it is your home we will obviously stay there.)
• Are you interested in any of my other prenatal or birth services?
  Belly Casting

  Birth Photography
• Yaaaa! Your done. Now just type the words in the blank space below (this helps me prevent spam) and click the 'Send Form' button to the right.

  I look forward to meeting with you. You should hear from me within 48 hours to set up a time for our interview.

Powered byEMF HTML Form
Report Abuse