Client Information Record

Bridging Birth Client Information Record

Today’Date_____EDD_____Doctor/Midwife______________Place of Birth___________
About You
Name___________________________________________________DOB________________
Occupation________________________Place of Work____________________________
Best contact information______________________________________________________
Partner__________________________________________________DOB________________
Occupation________________________Place of Work____________________________
Best contact information______________________________________________________
Address______________________________________________________________________
Siblings Names and Ages_____________________________________________________
Pets__________________________________________________________________________
Plan for care of children during birth___________________________________________
Plan for care of pets during birth______________________________________________
Others who may be with you during your birth_________________________________
______________________________________________________________________________
About Your Health Care Provider
Primary Provider______________________________________________________________
Type of practice (Private, clinic, group)_________________Phone_________________
Are you comfortable with your care provider?_________________________________
Do you have a sense of support or your vision of the birth?______________________
Concerns to address?________________________________________________________
Planned place of birth_________________________________Phone_________________
Back up Hospital if Home Birth/Birth Center_______________Tour?__Registered?___
Baby’s Health Care Provider (Pediatrician/GP)____________________Phone_______
Taken Childbirth Classes?___Name of class and Instructor?_____________________
Breastfeeding class?______Name of class and Instructor?_______________________
Other classes?(Exercise, Parenting, CPR, etc)__________________________________
______________________________________________________________________________
Other Health Care Providers you see (Chiropractic, Acupuncture, Therapist, Homeopathy, etc)____________________________________________________________
About Mom’s Health History
How is your health?___________________________________________________________
Any allergies? (Drugs, food, tape, latex, etc.)__________________________________
______________________________________________________________________________
Present exercise and frequency_______________________________________________
Are you receiving care for any other medical condition other than you pregnancy right now?___________If so, what?__________________________________
Taking any medications?_________
Have you ever taken medication or been hospitalized for emotional difficulties?
______________________________________________________________________________








About Your Birth
Mother: What is your vision for this birth (Please be specific, use a separate sheet of paper if necessary)________________________________________________________
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Parnter: What is your vision of this birth? (Please be specific, use a separate sheet of paper if necessary)________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What are your expectations of your Labor Assistant/Doula/Labor Support Provider?____________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What is your plan for coping with the potential pain of labor?___________________
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Do you have a birth plan?____________________Reviewed it with Caregivers?____
Have your Caregivers signed your birth plan?______________
Are you planning of having photos?__________________Video?__________________
Are you planning on having music?_______________Do you need a player?______
Any special ideas about what you might like for labor? (Sight, sound, smell, taste, touch)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Any special positions, breathing or relaxation techniques you have practiced or would like to use?____________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Anything else you would like me to know to best support you?__________________
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