Birth Plan and Postpartum Questionnaire

Helps expecting parents put their delivery and postpartum care preferences in writing before the baby arrives.

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Name

First Name

Last Name

Date of Birth

Race

Hospital

OBGYN

Please specify how you will deliver

Vaginal Birth Cesarean VBAC Undecided

Please list any medical/health concerns you have experienced throughout pregnancy if any

Do you have a support system for pregnancy and postpartum?

Yes No

If so, list below.

Below are options you can choose to set a calming atmosphere for your birth please check all that you would like

Music Dim Lighting Aromatherapy Candles Own Clothing Birth Photography

How will you travel to and from the hospital/birth center?

Please list your hospital, birthing center or home birth support person(s), relationship

Please select your feeding plans for the baby or babies

Breastfeeding Formula Combination Undecided

Please list your childcare plans for siblings during birth and hospital stay if needed

What type of support are you needing?

Do you or anyone in your family have allergies?

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