Sign Up for BirthWorks Class: Step 3

BirthWorks Class Questionnaire

Thank You for Choosing BirthWorks!

Please take the time to fill out this preliminary questionnaire to help me get to you better in preparation for our classes.

BirthWorks Clients Questionnaire

First Name: *
Last Name: *
Partner/Spouse's Name (if applicable)
Home Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Preferred Phone Number: *
Alternate Phone Number
Do you have text capabilities on either of the phone numbers above? *
(Check more than one, if applicable)Yes, on the Preferred NumberYes, on the Alternate NumberNo, neither number receives text
Email Address *
Baby's Estimated Due Date *
How long have you and your partner been together? (If applicable)
How are you feeling about this pregnancy? *
If you are employed, what is your occupation?
Are you planning to return to work after the birth? *
Yes, I plan to return to this or another jobNo, I plan to stay homeNot sure
If you will be returning to work, how soon will you be returning?
As of right now, where do you plan to birth? (Enter the name of hospital, or home birth, as applicable) *
What is the name of your health care provider for this pregnancy? (midwife or OB) *
What are your hopes for this birth? *
Do you have any concerns or fears about this birth or birth in general? *
Have you had any physical issues during this pregnancy?
Are you generally healthy, or have you often had illnesses and/or injuries?
If you have other children, please list their names and ages and if they live with you or elsewhere.
Have you experienced any miscarriages, stillbirths, death of a child, or made an adoption plan for a child? If so, please give the year(s).
What reading have you done about pregnancy and birth? *
If you have previously given birth, please describe your experiences: *
(Enter “none” if no previous birth experiences.)
Please describe your goals for or thoughts about feeding your baby, in as much or as little detail as you want. *
How do you feel about your current level of physical activity?
How do you feel about your eating habits and nutritional status?
Have you attended or heard about other childbirth preparation courses? If so, what were your thoughts?
Why did you choose BirthWorks? *
What is it that you'd like to get out of this class? *
What specific issues would you like to discuss? *
(If you have booked private sessions, please note that we can only cover so many topics in the limited time we have. So I ask that you list the topics that are the most important to you.)

Verification

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