*First and Last Name

*Choose your pronouns. *Choose your pronouns. she/her he/him they/them other

*Your Date of Birth

*Estimated Due Date

Partners Name

*Choose your partners pronouns *Choose your partners pronouns he/him she/her they/them other

*Home Adddress- INCLUDE CITY AND ZIP CODE

Any special directions or parking suggestions?

*Email Address

Include your partners email if they would like to be CCed in all our emails.

*Your Occupation

Partner's Occupation

*Your phone number with area code.

Partners phone number with area code.

Please list any other humans or pets that live with you.

*I confirm that I do not use artificial air fresheners, sprays or candles in my home. *I confirm that I do not use artificial air fresheners, sprays or candles in my home. YesNoUnsure

*Have you been pregnancy before? *Have you been pregnancy before?yesno

*Have you given birth before? *Have you given birth before?yesno

*Gender of baby. *Gender of baby.FemaleMaleSurprise!Non-binary

*Location you plan to deliver. *Location you plan to deliver.HomeSanta Theresa Kaiser (San Jose)Santa Clara KaiserRedwood City KaiserO'Connor HospitalGood Samaritan HospitalValley Med HospitalEl Camino Los GatosEl Camino Mountain ViewLucille Packard Childrens Hospital/StanfordSequioa HospitalUndecidedOther- not listed

*Name of careprovider and if applicable their group name.

*How would you rate your communication with your careprovider? *How would you rate your communication with your careprovider?Excellent!Great.Good.OKNot so good.Bad.

*Check off classes you plan to take or have taken. *Check off classes you plan to take or have taken. childbirth preparation baby care breastfeeding CPR/first aide other none

What other classes are you taking or plan to take?

What books and websites have you been reading?

*What kind of exercise do you do weekly?

*How have you been generally feeling this pregnancy?

Briefly list any pregnancy discomforts you are currently experiencing.

List any pregnancy complications you have been diagnosed with.

List any medical, food or environmental allergies and sensitivies you have.

List any supplements, vitamins and medications you are taking.

*Check off any of the following that you have been diagnosed with. *Check off any of the following that you have been diagnosed with. HIV/AIDS Genital Herpes HPV Gestational Diabetes/Diabetic Hypertension (High Blood Pressure) RH- Group B Strep + Heart Disorders Thyroid Disorders Other unlisted. None of the above.

*Check off any of the following mood disorders you have been diagnosed with now or in the past. *Check off any of the following mood disorders you have been diagnosed with now or in the past. Depression Anxiety OCD Bipolar Other None

*Check off any of the following medical procedures you have had involving the uterus, cervix or vagina. *Check off any of the following medical procedures you have had involving the uterus, cervix or vagina. Removal of tissue after a miscarriage. Insertion of IUD Treatment for an unusual pap smear. Removal of genital warts. Cryosurgery/LEEP procedure. Cervical or uterine biopsy. Removal of polyps. D&C Uterine or cervical fibroids. Other None

*Check off any of the following breast procedures or diagnosis that apply. *Check off any of the following breast procedures or diagnosis that apply. Breast reduction/augmentation. Breast surgery of any kind. Pierced nipples. IGT/Hypoplasia Flat or inverted nipples. Other None

*Have your breasts changed during pregnancy? *Have your breasts changed during pregnancy? yes no I don't know.

List any serious injuries or accidents you have had.

Have you experienced any life trauma/ abuse that may effect how you labor/ birth? If yes, how can I help you feel safe during your birthing time?

List any other medical, physical or mental issues you think I should know about.

Does anyone in your home smoke, drink alcohol regulary, or take illegal drugs? If yes, please explain.

Do you store guns outside of a locked safe in your home? Do you store guns outside of a locked safe in your home? yes no

Does anyone in your home have behavioral issues or on the spectrum? If yes, please explain.

*How do you usually cope with pain in your daily life? Do you prefer holistic methods or western medicine?

*Check off alternative practitioners you use or have used in the past. *Check off alternative practitioners you use or have used in the past. professional massage chiropractor acupuncturist herbalist craniosacral reiki/energy work other none of the above

Do you have any religous and/or spiritual affiliation or special customs that I should know about?

*Please describe to me your ideal birth.

*In what ways do you want me to support you and your partner during our prenatal visits?

*In what ways do you want me to support you and your partner during your postpartum check in?

In what ways does your parnter want to be involved prenatally, birthing and postpartum?

Is there anything else you would like for me to know? Any questions, concerns or topics you would like to cover at our first prenatal?