Case History for Pregnant Mothers

Name: ______Estimated Due Date: ______

Prenatal history: Previous Birth History:

1) Is this your first pregnancy ______1) Place of birth: hospital, birthing center, home. 2) How many other births have you had 2) Delivering Practitioner: OB/Gyn, Certified Nurse ______Midwife, Certified Practicing Midwife, Lay Midwife 3) How many weeks pregnant are you now Name ______3) Position of Delivery: On your back, on Your Side, 4) Have you experienced any traumas during this Kneeling, Squatting, Other? pregnancy ______Please describe 4) Was labor induced? Yes No Unknown ______If yes, specify type: Pitocin, Prostagland Gel, Foley bulb, 5) Any medications taken during this pregnancy Unknown, Other ______5) Did your membranes rupture naturally? Yes No 6) Do you smoke or drink alcohol By your care provider? Yes No Unknown ______6) Were contractions stimulated with pitocin once? Yes 7) Have you had any evaluation procedures No Unknown ______7) Did you receive any pain medications or anesthesia? 8) Please list dates, frequency and reason for these Yes No Unknown procedures: Please specify type used______If you had an epidural, how many centimeters were you ______dilated when it was administered? 9) How has your diet been during this pregnancy ______8) Did you experience back pain during labor? 10) Have your taken your Glucose Tolerance Test Yes No Unknown ______Results ______9) How long was labor? ______Pushing? ______11) Pre-pregnancy weight______10) Did you deliver vaginally? Yes No Current weight ______11) Baby presentation at time of delivery: Normal, 12) Have there been any stressful events in your life Posterior, Brow, Facial, Breech during this pregnancy______If breech, specify type: Footling, Frank, Complete or ______Kneeling ______12) Did you have a C-Section? Yes or No ______13) Was there any visible injury to your baby? Yes No 13) What are your most significant fears associated with Unknown If so, where on your baby was the injury this birth? ______sustained?______14) Did your care provider assist delivery with his/her ______hands? Yes No Unknown 14) Who is your birth care provider 15) Were operative devices used to facilitate the birth? ______Yes No Unknown Which type? Forceps Vacuum 15) Who will be supporting you during birth Extraction ______16) Was there a birthing coach present? husband, doula, ______friend, other, please specify:______16) Where do you plan on delivering 17) At what week of pregnancy was your baby born? ______17) Have you put together a birth plan 18) Did you breastfeed? Yes or No ______19) How long did you breastfeed? ______18) Is baby Breech: Yes No Unknown 20) Did you have any issues with breastfeeding? 19) Have you had any procedures to turn baby: ______Chiropractic, Acupuncture, Manual Version ______