New Client Birth Questionnaire

BIRTH QUESTIONNAIRE
The information you provide here helps us to preplan your birth session enabling us to get the most out of your experience.
Birthing Mum's Name Birthing Mum's Name * First Last
Partners Name (if applicable) Partners Name (if applicable) First Last
Email *
Mum's Mobile Number
Birth Partners Mobile Number
Emergency Contact Name Emergency Contact Name First Last
Emergancy Contact Mobile Number
Relationship to Mother
Do you know the gender / name of your baby?
Birth Information
Babies Estimated Due Date Babies Estimated Due Date * / DD / MM YYYY
Where do you plan to birth your baby?
Address of birth location Address of birth location
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Your Doctor / Midwife / Provider's Name
What is your current birthing plan?
Will this be your first birth experience?

Will this be your first birth experience? Yes No
Have you spoken to your doctor about having a photographer attend your birth?

Have you spoken to your doctor about having a photographer attend your birth? Yes No
In the event of a C-section, have you spoken with your doctor about allowing photography in the OR?

In the event of a C-section, have you spoken with your doctor about allowing photography in the OR? Yes No
Will you have a doula or other support team member present?

Will you have a doula or other support team member present? Yes No
Do you plan on having your child(ren) present at the birth?

Do you plan on having your child(ren) present at the birth? Yes No
Please list important family that will be in attendance at the birth (any grandparents, siblings, etc. This helps me know who to look for at the nursery window, etc).
What point of view would you like the photos to be taken?

What point of view would you like the photos to be taken? Behind mums shoulder Doctor / Midwife Perspective Mixture of both What ever is going to work best at the time
Please nominate the particular elements of the labor and birth you would specifically like me to capture?

Please nominate the particular elements of the labor and birth you would specifically like me to capture? Partner Support The baby's head as it crowns Bonding moments with specific family members The placenta Other Other
Would you like me to leave the room during particular situations or procedures? *note that procedures will not be photographed unless requested at the time AND authorised by medical staff*

Would you like me to leave the room during particular situations or procedures? *note that procedures will not be photographed unless requested at the time AND authorised by medical staff* Epidural Internal Exams Emergency Situations Vomiting Other Other
Are there any goals or details within your birth plan that you would like to share with me? Knowing your plan can assist me in providing consistent support with the others in attendance.
Are you at risk of premature delivery?
Have you had any complications with this pregnancy?
Tell me about your previous births

Ie. For each of your previous births: were they spontanious, induced, a booked or emergency c-section? did you or your baby have any complications, how close to your estimated due date did they arrive? Was labour fast, slow, stalled? Do you know how long you were in active labour? Where did you birth? How do feel about your previous birth/s. How did your support person feel about the birth? Anything else you feel is relevant to tell me?
Is there anything you would like to add?
Thank you!!

New Client Birth Questionnaire

BIRTH QUESTIONNAIRE

Birth Information

Tell me about your previous births

Thank you!!