Mother's Name

First Name Last Name

Mother's Phone

Area Code Phone Number

Mother's E-mail

Partner's Name

First Name Last Name

Partner's Phone

Area Code Phone Number

Partner's Email

Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Estimated Due Date

Month Day Year

Birth Place

Provider

# Pregnancy

# of Children

Have you taken childbirth classes in the past?

Yes No

In what ways have you prepared for childbirth during this pregnancy? (Books, Movies, Websites, Classes)

What areas of pregnancy, childbirth and postpartum do you hope to learn about in class?

What are your plans for coping and comfort during labor and birth?

How do you see your partner's role during labor and birth?

How has your pregnancy been so far?

Do you exercise regularly?

Yes No Sometimes

How would you describe your diet?

Do you plan to breastfeed?

Yes No Maybe

Any other information of concerns?

Have you taken any childbirth classes in the past?

Yes No

In what ways have you prepared for childbirth during this pregnancy? (Books, Movies, Websites, Classes)

What areas of pregnancy, childbirth and postpartum do you hope to learn about in class?

What is your understanding of her wishes for coping and comfort during labor and birth?

How do you see your role during labor and birth?

Do you exercise regularly?

Yes No Sometimes

How would you describe your diet?

Would you like her to breastfeed?

Yes No

Any other information or concerns?

Private Childbirth Class Form

Mother