New Client Birth Questionnaire
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Estimated Due Date:
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Mother's Full Name:
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First, Last
Primary Phone #:
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Alternate Phone #:
Primary Email Address:
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Partner's Name
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First, Last
Address Line 1:
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Address Line 2:
City:
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State:
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ZIP Code
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Current Birth Plan:
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Spontaneous Labor
Induction
C-section
Location Type:
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Hospital
Birth Center
Home
Other
Location Address:
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Address Line 1, Address Line 2, City, State, ZIP
Care Provider:
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Doctors Name
Name of Practice:
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People in Attendance:
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Partner
Grandparent(s)
Doula(s)
Sibling(s)
Friend(s)
Midwife
Videographer
List any people that will be attending the birth of your baby. Check any that apply.
Others – Please Explain:
Current Pregnancy:
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Normal with no complications
High risk
Preterm labor / dilation
Some complications, but no concern as of now
How is it progressing? Check any that apply.
Other – Please Explain:
Past Labors:
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This is my first labor
Preterm labor
Within 1 week of EDD
1+ week past EDD
Within a few days of EDD
Quick
Even pace
Slow
Natural
Induction
Scheduled C-section
Emergency C-section
Preterm baby
Mom interventions
Baby interventions
If this is not your first labor, can you please describe how you past labor/deliveries have gone? Check any that apply.
Other – Please Explain:
Do you know the gender of your baby?
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Yes, girl
Yes, boy
No, we haven’t found out yet
No, we are waiting until the baby is born to find out
Transfer
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Follow
Wait for instruction
If for any reason you are to be transferred from home to hospital or from one hospital to another for any reason, would you want me to…
What I Would Like Photographed:
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Labor
Family in attendance
Care Providers – with permission
Nudity ok
Nudity not ok
Crowning shot
Side shot during delivery
Over the shoulder during delivery
Nursing
First bath
Weight/Height
Foot Prints
Family with baby
Images with care provider and/or nurses
Check any that apply.
Other – Please Explain:
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From above, what is your most important?
I want most of my pictures to be of:
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My labor experience (my team helping, different positions I try, the overall scene throughout my laboring)
The moment the baby comes (everyone’s reactions, the baby!)
My sweet, new baby (at arrival, but also perhaps a small photo session a little while later)
I’d really just like a good mix of everything!
Are you comfortable with me posting non-identifying social media updates and non-revealing photos about your labor & delivery experience?
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Sure
It’s okay as long as you are very subtle
Please don’t post anything
Do you want to be tagged in images on social media?
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Yes, please!
No thanks, I’ll tag myself if I want to.
Any additional comments or information?
Have you advised your medical team and family that you'll have a professional photographer attending your birth?
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Yes
No
Submit