Client Questionnaire

Thank you for your interest in Itur Ad Astra Birth Services! I am excited to have our first initial consultation and I hope you are too! Keeping in mind that our first consultation is just a way for us to get to know each other better and to make sure we are a good fit for each other, please fill out this form so that I can better know you and your birth goals.

All information in the form is kept confidential and will never be shared with anyone without your written permission.

All questions are voluntary.  

 

Please complete the form below

Name *
Name
Partner's Name
Partner's Name
Home Address
Home Address
Phone *
Phone
Partner / Other Phone
Partner / Other Phone
Your Birth Date
Your Birth Date
Health Care Provider Information
Type of Provider
Location Where You Plan To Give Birth
General Health Information
Previous Pregnancy Information
Have you given birth to multiples?
Have you placed any children for adoption?
Have you adopted any children?
Which types of births have you experienced? (Select all that apply)
Have you had any of the following pregnancy-related health conditions in PAST pregnancies?
Current Pregnancy Information
Baby's Due Date
Baby's Due Date
Are you expecting multiples? (Twins, triplets, etc.)
What type of birth are you planning?
How do you plan to birth:
Birth Wishes
Do you think labor will hurt?
Rate how much you would like or not like each of the following to occur during your childbirth experience
Rate how much you would like or not like each of the following to occur during your childbirth experience
Stripping Membranes
Induced Labor
Pitocin Augmentation
Artificial Rupture of Membranes
Wearing a hospital gown
Having a saline lock
Having an IV
Not being allowed to eat or drink
Being confined to bed
Narcotic pain meds
Epidural
Urinary Catheter
Continuous external fetal monitoring
Internal fetal scalp monitoring
Pushing on your back
Episiotomy
Perineal Tear
Vacuum-assisted or forceps delivery
Cesarean Birth
Immediate cord clamping
Immediate skin-to-skin contact
Delay newborn exam procedures
Cord traction
Deep suctioning of baby's airways
Antibiotic Ointment in baby's eyes
Vitamin K injection (baby)
Hep B injection (baby)
Keeping your placenta
Baby being bathed shortly after birth
Circumcision