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MoonDragon's Pregnancy Information
CLIENT REGISTRATION FORM
(This is a webpage reproduction of my client file forms.)




CLIENT REGISTRATION FORM

Name ____________________________________ Age _______ Birthdate (mo/da/yr) __________________
Address______________________________State________Zip_______ Home Phone___________________
Education___________________Occupation______________________Work Phone___________________
Do you own a computer?_________Mac or IBM-PC?_________Internet Access?_____________________
E-mail address___________________________ Website__________________________________________
Religion________________ Describe Religious Birth & Medical Issues _____________________________
___________________________________________________________________________________________
Hobbies & Interests_________________________________________________________________________
___________________________________________________________________________________________




Father/Partner/Support Name__________________Age________Birthdate (mo/da/yr)________________
Address______________________________State_________Zip_______ Home Phone__________________
Education___________________Occupation_______________________Work Phone__________________
Do you own a computer?________Mac or IBM-PC?___________Internet Access?____________________
E-mail address____________________________ Website_________________________________________
Religion________________Describe Religious Birth & Medical Issues______________________________
___________________________________________________________________________________________
Hobbies & Interests_________________________________________________________________________
___________________________________________________________________________________________




DIRECTIONS:
On a separate piece of paper or on the back of this registration history form, please draw a map and detailed instructions on how to find your home.

EMPLOYMENT ISSUES:
Are you currently employed?_________________If yes, please describe where you work, what you do, and how many hours you work daily. __________________________________________________
When do you plan to discontinue working?________________Comment on your present plans for going back to work after your baby is born._________________________________________________

HABITS & MEDICATIONS:
Do you smoke? __________ What & how often?______________________________________________
Does anyone else in your household smoke?____________What & how often?__________________
Do you drink alcohol?__________How often & amount?_______________________________________
Do you drink coffee?________________Cups per day/week_____________________________________
Other caffeinated or sugared beverages?____________________________________________________
Do you use recreational drugs?__________What & how often?_________________________________
Do you take prescription medications?__________What & how often?__________________________
Do you use over-the-counter medications & nutritional supplements?__________________________
Please list all medications & supplements use, their purpose, and dosage._____________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Are you willing to cease potentially harmful & unhealthy habits or lifestyles or cease taking non-life threatening medications during pregnancy?_______________________________________________
While breastfeeding?__________All medications (over-the-counter and prescription medications, including any nutritional supplements, should be discussed with your midwife before using during pregnancy. Comments___________________________________________________________________
During the 3 months prior to conception & during this pregnancy, have you undergone any therapy or used drugs to treat a medical or an emotional condition? Include use of any drug, especially those given just to pregnant women such as sleeping aids, diuretics, tranquilizers, antidepressants, appetite suppressants, anti-nausea pills, antibiotics, etc.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Do you spend a lot of time around volatile chemicals, paints, pesticides, adhesives, smoke, or other potentially dangerous chemical compounds?________________________________________________
_________________________________________________________________________________________


HOUSEHOLD PETS:
Do you have pets?________________________________________________________________________
List type of pet & household caretaker _____________________________________________________
Do you have someone else to care for your pet(s) during your pregnancy, birth, & afterward, if needed?_________________________________________________________________________________
Do your pets have access to your planned birthing area?___________ Do you have someplace else where the pet may be kept during prenatal visits, birth, and postpartum visits?__________________


MENSTRUAL HISTORY:
Age of first menstrual period__________________Average length of cycle (days)__________________
Are you regular?_____________________________Average length of flow (days)___________________
Do you have PMS symptoms?__________Describe or comment about any problems_______________
__________________________________________________________________________________________
What is your normal amount of flow? (light) (medium) (heavy)__________________________________
Date of your last period (mo/day/yr)________________________Was it normal?____________________
Comments________________________________________________________________________________


BIRTH CONTROL HISTORY:
Have you used birth control methods in the past?____________________________________________
Please list methods used & comment on the success, problems, or failures in any given method, & dates they were used._____________________________________________________________________
_________________________________________________________________________________________
Were you using birth control when you conceived?___________________________________________
If so, what kind and for how long?__________________________________________________________
_________________________________________________________________________________________
What method of birth control do you plan on using after the birth of this baby?__________________
_________________________________________________________________________________________


PREGNANCY & BREASTFEEDING ISSUES: (PAST HISTORY)
Total number of pregnancies including miscarriages and abortions (Gravida)___________________
How many were spontaneous miscarriages?____________ Complications?_______________________
How many were elective medical abortions?____________ Method used_________________________
Reasons for procedure?____________________________________________________________________
Complications?_____________________________________Ectopic pregnancies?___________________
How many were stillbirths? __________ Why were they stillborn?_______________________________
Complications?___________________________________________________________________________
Total number of live births (Para)_____________Are they all living now?_________________________
If not, please explain circumstances ________________________________________________________
Premature births (28 weeks to 37 weeks gestation)_________Complications?_____________________
Full term births (37 weeks to 42 weeks gestation)___________Complications?____________________
Post-mature births (after 42 weeks gestation)______________ Complications?_____________________
Multiple births? (Twins, Triplets, etc.)____________________ Complications?_____________________
Caesareans?____________ Reason?__________________________________________ VBACs?_______
How many hospital births have you had?______Birth Center?______Homebirths?_________________
Explain the types of birth attendants you have experienced with your last births:
_________________________________________________________________________________________
_________________________________________________________________________________________
Did you breastfeed your baby(s)?__________For how long?____________________________________
Any problems?___________Explain?_________________________________________________________


PREGNANCY & BREASTFEEDING ISSUES: (PRESENT PREGNANCY)
Was this pregnancy planned?_________ How do you feel about this pregnancy?__________________
How does the father/partner feel about this pregnancy?________________________________________
What are your feelings about breastfeeding?__________________________________________________
Do you want to breastfeed this baby?__________For how long?__________________________________
Anything special you want to learn about concerning breastfeeding and/or baby care?____________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please list your last two menstrual periods & indicate if you are absolutely sure of the dates or estimating. Your last menstrual period ______________ Previous menstrual period ________________
Do you know when you ovulated?___________________________________________________________
Do you know when you may have conceived?_________Have you felt the baby move?____________
When?___________________________________________________________________________________
How many weeks pregnant are you?______Date fetal heart was first heard______________________
Was this by a fetoscope (stethoscope), Doppler, or ultrasound?_________________________________
Have you had an ultrasound done?_____________When?__________By whom?____________________
Results____________________________________________________________________________________


QUESTIONS ABOUT YOUR MOTHER: Did your mother breastfeed?______Were you breastfed?_______
Describe your mother's attitude toward birth and breastfeeding_________________________________
How many pregnancies did your mother have?_______Miscarriages?_______Premature?___________
Did your mother have multiple births (twins, triplets)__________________________________________
If a multiple birth, what was Your birth order? (first) (second) (third)______________________________
Did she have any other obgyn problems dealing with her pregnancies or births?__________________
__________________________________________________________________________________________
__________________________________________________________________________________________


PRENATAL HEALTH:
What kind of regular exercise do you get?____________________________________________________
Do you meditate or practice yoga?__________ How much do you sleep at night?__________________
Do you have the opportunity to sleep during the day?________ How often?_______________________
Do you sleep well?_____________What do you do when you can't sleep?_________________________


PRENATAL CARE:
Have you had prenatal care during this pregnancy? ________Where & with whom?_______________
Will you want to continue to receive care from this service along with the care you receive from MoonDragon Birthing Services?_____________Will they continue to provide care in the event of a medical emergency transport or discontinuation of our services?________________________________
What are their view regarding homebirths, doulas, and non-nurse-midwifery services?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________


PREGNANCY & BIRTH HISTORY:
Child #1: Name____________________________________Birth Date (mo/da/yr)______________________
Birth Place (city/state/country)_______________________________________________________________
Birth Location (hospital/birth center/home/other)_______________________________________________
Was this location planned?_____If not, where was the birth originally planned?___________________
Who was the planned birth attendant (unattended/father/midwife/CNM/physician)?________________
Who was the actual birth attendant?________Was this a planned pregnancy?_____________________
1st sign of labor____________________________________________________________________________
Length of 1st stage__________________________________________________________________________
Length of 2nd stage?________________________________________________________________________
I.V. used?________ Was this labor induced or augmented? _______ Oxytocin used? _______________
Drugs used in 1st stage _____________________ Drugs used in 2nd stage __________________________
Complications ______________________________ Vaginal or caesarean delivery ___________________
Episiotomy/tears _______________ Sutures required ____________ Medication used ________________
Birth presentation (face down, face up, breech or other) _______________________________________
Describe any procedures used to change presentation _________________________________________
Was it successful?__________________________________________________________________________
Weight & length of baby (lbs/oz) __________________________________ (inches) __________________
Weeks gestation_______________Problems with baby?_________________________________________
Length of 3rd stage_________Hemorrhage?____________Placental problems?____________________
Breastfed?_____________How long?_______________Breastfeeding problems?____________________
Did you take childbirth preparation classes?___________ If so, what kind?________________________
Did they help you with labor and birth management?__________________________________________
Type of pregnancy termination (spontaneous live birth/ induced live birth/still birth/ medical abortion/spontaneous miscarriage-abortion/other)____________________________________________
If you are Rh negative, did you receive Rhogam after this abortion, miscarriage, or birth?
__________________________________________________________________________________________
Comments_________________________________________________________________________________





Child #2: Name____________________________________Birth Date (mo/da/yr)______________________
Birth Place (city/state/country)_______________________________________________________________
Birth Location (hospital/birth center/home/other)_______________________________________________
Was this location planned?_____If not, where was the birth originally planned?___________________
Who was the planned birth attendant (unattended/father/midwife/CNM/physician)?________________
Who was the actual birth attendant?________Was this a planned pregnancy?_____________________
1st sign of labor____________________________________________________________________________
Length of 1st stage__________________________________________________________________________
Length of 2nd stage?________________________________________________________________________
I.V. used?________ Was this labor induced or augmented? _______ Oxytocin used? _______________
Drugs used in 1st stage _____________________ Drugs used in 2nd stage __________________________
Complications ______________________________ Vaginal or caesarean delivery ___________________
Episiotomy/tears _______________ Sutures required ____________ Medication used ________________
Birth presentation (face down, face up, breech or other) _______________________________________
Describe any procedures used to change presentation _________________________________________
Was it successful?__________________________________________________________________________
Weight & length of baby (lbs/oz) __________________________________ (inches) __________________
Weeks gestation_______________Problems with baby?_________________________________________
Length of 3rd stage_________Hemorrhage?____________Placental problems?____________________
Breastfed?_____________How long?_______________Breastfeeding problems?____________________
Did you take childbirth preparation classes?___________ If so, what kind?________________________
Did they help you with labor and birth management?__________________________________________
Type of pregnancy termination (spontaneous live birth/ induced live birth/still birth/ medical abortion/spontaneous miscarriage-abortion/other)____________________________________________
If you are Rh negative, did you receive Rhogam after this abortion, miscarriage, or birth?
__________________________________________________________________________________________
Comments_________________________________________________________________________________


Please ask the midwife for extra pages if you have more than 2 previous pregnancy/births.




Child #_____: Name_______________________________Birth Date (mo/da/yr)______________________
Birth Place (city/state/country)_______________________________________________________________
Birth Location (hospital/birth center/home/other)_______________________________________________
Was this location planned?_____If not, where was the birth originally planned?___________________
Who was the planned birth attendant (unattended/father/midwife/CNM/physician)?________________
Who was the actual birth attendant?________Was this a planned pregnancy?_____________________
1st sign of labor____________________________________________________________________________
Length of 1st stage__________________________________________________________________________
Length of 2nd stage?________________________________________________________________________
I.V. used?________ Was this labor induced or augmented? _______ Oxytocin used? _______________
Drugs used in 1st stage _____________________ Drugs used in 2nd stage __________________________
Complications ______________________________ Vaginal or caesarean delivery ___________________
Episiotomy/tears _______________ Sutures required ____________ Medication used ________________
Birth presentation (face down, face up, breech or other) _______________________________________
Describe any procedures used to change presentation _________________________________________
Was it successful?__________________________________________________________________________
Weight & length of baby (lbs/oz) __________________________________ (inches) __________________
Weeks gestation_______________Problems with baby?_________________________________________
Length of 3rd stage_________Hemorrhage?____________Placental problems?____________________
Breastfed?_____________How long?_______________Breastfeeding problems?____________________
Did you take childbirth preparation classes?___________ If so, what kind?________________________
Did they help you with labor and birth management?__________________________________________
Type of pregnancy termination (spontaneous live birth/ induced live birth/still birth/ medical abortion/spontaneous miscarriage-abortion/other)____________________________________________
If you are Rh negative, did you receive Rhogam after this abortion, miscarriage, or birth?
__________________________________________________________________________________________
Comments_________________________________________________________________________________





Child #_____: Name_______________________________Birth Date (mo/da/yr)______________________
Birth Place (city/state/country)_______________________________________________________________
Birth Location (hospital/birth center/home/other)_______________________________________________
Was this location planned?_____If not, where was the birth originally planned?___________________
Who was the planned birth attendant (unattended/father/midwife/CNM/physician)?________________
Who was the actual birth attendant?________Was this a planned pregnancy?_____________________
1st sign of labor____________________________________________________________________________
Length of 1st stage__________________________________________________________________________
Length of 2nd stage?________________________________________________________________________
I.V. used?________ Was this labor induced or augmented? _______ Oxytocin used? _______________
Drugs used in 1st stage _____________________ Drugs used in 2nd stage __________________________
Complications ______________________________ Vaginal or caesarean delivery ___________________
Episiotomy/tears _______________ Sutures required ____________ Medication used ________________
Birth presentation (face down, face up, breech or other) _______________________________________
Describe any procedures used to change presentation _________________________________________
Was it successful?__________________________________________________________________________
Weight & length of baby (lbs/oz) __________________________________ (inches) __________________
Weeks gestation_______________Problems with baby?_________________________________________
Length of 3rd stage_________Hemorrhage?____________Placental problems?____________________
Breastfed?_____________How long?_______________Breastfeeding problems?____________________
Did you take childbirth preparation classes?___________ If so, what kind?________________________
Did they help you with labor and birth management?__________________________________________
Type of pregnancy termination (spontaneous live birth/ induced live birth/still birth/ medical abortion/spontaneous miscarriage-abortion/other)____________________________________________
If you are Rh negative, did you receive Rhogam after this abortion, miscarriage, or birth?
__________________________________________________________________________________________
Comments_________________________________________________________________________________


Please ask the midwife for extra pages if you have more previous pregnancy/births.




CURRENT HEALTH & MEDICAL CARE PRACTITIONERS:
Please list current healthcare providers for you and your family with address, phone numbers & information that may assist us in your care:
Family Practitioner:_____________________________________________________________________
OB/GYN:_________________________________________________________________________________
Allergist________________________________________________________________________________
Pediatrician_____________________________________________________________________________
Gastroenterologist_______________________________________________________________________
Chiropractor_____________________________________________________________________________
Homeopathist_____________________________________________________________________________
Naturopath_______________________________________________________________________________
Acupuncturist____________________________________________________________________________
Massage Therapist________________________________________________________________________
Reiki Therapist__________________________________________________________________________
Psychotherapist__________________________________________________________________________
Dentist__________________________________________________________________________________
Other____________________________________________________________________________________


EMERGENCY TRANSPORT OR REFERRAL:
In the event of a medical emergency, where would you prefer to receive continued medical care & with whom: ____________________________________________________________________________
Please list all emergency contact persons including child care services, emergency transport, hospital, physician, and family members:____________________________________________________
_________________________________________________________________________________________
Most homebirths occur without any or very little interference from your midwife, however, there are occasionally times in which options must be reviewed and discussed regarding difficulties that may arise in a birthing situation. These difficulties also arise in hospitals and birth centers as well, along with many more that tend to be associated specifically with these birthing sites (e.g.,higher incidence of technological & surgical mistakes, increased infections, increased hemorrhages, medication reactions, etc.). Would you be open to discussion and willing to consider options in trying various techniques and/or procedures that may be uncomfortable, risky, or may be considered medically unorthodox and outside of established homebirth guidelines if these procedures are thoroughly explained with pros and cons, potential risks, and dangers. You midwife mayor may not be willing to try them, but they may be an option open to you in an attempt to prevent an emergency transport and further unwanted intrusive medical procedures or a caesarean delivery. (examples may include, but not be limited to breech presentation delivery, multiple birth deliveries, external or internal fetal position manipulation, cervical massage, manual placental removal, bimanual uterine compression, suturing without medication, etc.)________________________________________________________________________________________
Please list certain complications or situations in which you may choose to be medically transported______________________________________________________________________________
_________________________________________________________________________________________
Complications or situations in which you may NOT choose to be medically transported
_________________________________________________________________________________________
_________________________________________________________________________________________
Would you be willing to sign an informed medical consent/waiver/release form once you are informed and accept the potential risks that may accompany these procedures and/or techniques if asked by the midwife in attendance?__________ Comment on how you feel if this pregnancy terminated in a hospital if you midwife feels the complication that is arising is such that needs transporting?_____________________________________________________________________________
With unwanted medical procedures after transport? __________ By cesarean? __________________


MEDICAL & DENTAL INSURANCE:
Do you have medical health insurance?_____________Many insurances do not cover homebirth or any out-of-hospital birth expenses and midwives. Have you checked with your insurance policy to find out if your insurance will be for these services?_____________Does your insurance cover Chiropractic / Naturopathic / Acupuncturist expenses?_____________Do you have dental insurance?___________Do you have to have a referral to use outside care?____________________ Will your insurance cover laboratory and/or diagnostic procedures if they are needed?____________________________Please list all health insurances you have available, policy numbers, primary care physician, and services they cover along with deductible or co-payment arrangements and prescription coverage:
________________________________________________________________________________________
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PSYCHOLOGICAL & EMOTIONAL ISSUES:
Describe any emotional problems you have had/are having?________________________________
Have you ever been molested or raped?___________________________________________________
Have you ever been a victim of domestic abuse?__________ Are you in an abusive relationship now?________________Do you need or have you received professional help and counseling for these issues?____________________________Are you currently taking any medications?__________ If so, please list medication, dosage, purpose, & with length of Time that you have been taking them: _________________________________________________________________________________________
Is anyone in your family abusive with children?______________________________________________
Comments________________________________________________________________________________


PATERNAL (BABY'S FATHER) MEDICAL STATUS:
Height _________ Weight __________ Body build ______________ Blood type & Rh factor__________
Relationship to you _______ Has he been tested for HIV? _____ When? _______ Result? ___________
Viral Hepatitis? __________ Type (A, B, C, Other) __________ Result __________If, positive, is he receiving medical treatment?____________ Has he been treated for any STDs (sexually transmitted diseases)_______________________If so, what type?_______________List any other health problems he may have _____________________________________________________________________________


MATERNAL & FAMILY MEDICAL HISTORY:
Have you, your baby's father, or immediate family member had any of the following problems: (check and circle any that apply and who they apply to, such as self, husband, mother, father, sister, brother). Describe problem/treatment.
Circulatory:
___Heart Problems (Arrhythmia) (Tachycardia) (Angina) (Murmur) (Other)________________________
___Circulation Disorders (Extremity Coldness, Discoloration, Numbness) (Other)__________________
___Blood Pressure (Hypertension [high]) (Hypotension [low]) (Other)_____________________________
___Anemia (Iron) (Folic Acid) (Sickle Cell) (Thalassemia) (Other)________________________________
___Bleeding Disorders (clotting factor) (hemophilia) (heparin therapy) (platelet) __________________
___Hemorrhoids (anal) (rectal) (other)_________________________________________________________
___Varicose Veins (genitalia) (legs) (other)____________________________________________________
___Transfusions____________________________________________________________________________
___Pre-eclampsia / Eclampsia _______________________________________________________________
Neurologic:
___CNS Disorders___________________________________________________________________________
___Epilepsy________________________________________________________________________________
___Convulsions (Non Epileptic) ______________________________________________________________
___Severe Headaches or Migraine Headaches_________________________________________________
Psychological:
___Post Traumatic Stress Syndrome_________________________________________________________
___Domestic / Sexual Abuse Syndrome_______________________________________________________
___Depression______________________________________________________________________________
___ADHD/HD/Attention/Hyperactive____________________________________________________________
___Mood Swings / Bipolar / Manic Depression_________________________________________________
___Multiple Personalities____________________________________________________________________
___Psycho-Social Disorders__________________________________________________________________
___Psychological Therapy___________________________________________________________________
___Addictive Personality_____________________________________________________________________
___Obsessive / Compulsive Disorder__________________________________________________________
___Paranoia / Phobias_______________________________________________________________________
___Violent Rages___________________________________________________________________________
___High Stress Syndrome___________________________________________________________________
___Insomnia_______________________________________________________________________________
___Extreme Exhaustion/ Chronic Fatigue_____________________________________________________
___Nightmares ____________________________________________________________________________
___Narcolepsy_____________________________________________________________________________
___Other__________________________________________________________________________________
Endocrine:
___Pituitary Disorders______________________________________________________________________
___Thyroid (Hypothyroid) (Hyperthyroid)______________________________________________________
___PMS / Hormonal_______________________________________________________________________
___Pre/Peri/Post Menopausal_______________________________________________________________
___Oxytocin Insufficiency__________________________________________________________________
___Hormonal Infertility / Therapy___________________________________________________________
___Pancreatic Disorders (Diabetes) (Hypoglycemia) (Hyperglycemia)____________________________
GastroIntestinal / Eliminatory:
___Pyloric Stenosis / Intestinal Constrictions__________________________________________________
___Heartburn / Acid Reflux_________________________________________________________________
___Ulcers_________________________________________________________________________________
___Constipation / Diarrhea / Colitis / Irritable Bowel_____________________________________________
___Parasites________________________________________________________________________________
___Appendicitis____________________________________________________________________________
___Hepatitis / Hepatitis Therapy_____________________________________________________________
___Gall Bladder / Gall Stones________________________________________________________________
___Kidney Disease / Kidney Stones / Kidney Infections________________________________________
___Bladder Disease / Bladder Infections______________________________________________________
Pulmonary:
___Respiratory Infections (RSV) (URI) (Whooping Cough) (Diphtheria)_____________________________
___Bronchitis / Emphysema / Asthma / COPD __________________________________________________
___Tuberculosis / Pneumonia_______________________________________________________________
___SIDS / Respiratory Apnea_______________________________________________________________
Immunological:
___Immunity Disorders ____________________________________________________________________
___Vaccine Reactions______________________________________________________________________
___Allergies (Hayfever) (Food) (Medications) (Animal) (Insect) (Environmental)
__________________________________________________________________________________________
___Immunity or Allergy Therapy_____________________________________________________________
Infectious Disease:
___Measles (3 day German - Rubella) (7 day - Rubeola)________________________________________
___Roseola Infantum_____________________________________________________________________
___Herpes (Zoster - Shingles) (Simplex 1-Oral) (Simplex 2-Genital)______________________________
___Chicken Pox - Varicella________________________________________________________________
___Small Pox - Varicola___________________________________________________________________
___Infectious Mononucleosis_______________________________________________________________
___Scarlet Fever (Scarlitina)______________________________________________________________
___Rheumatic Fever______________________________________________________________________
___Poliomyelitis__________________________________________________________________________
___Mumps________________________________________________________________________________
___Meningitis_____________________________________________________________________________
___HIV / AIDS_____________________________________________________________________________
___Viral Hepatitis (Hep A) (Hep B) (Hep C) (Hep D) (Hep E) ______________________________________
___Rabies_________________________________________________________________________________
___Encephalitis____________________________________________________________________________
___Sexually Transmitted Disease (Candida) (Genital Warts) (Gonorrhea) _________________________
___Sexually Transmitted Disease (Syphilis) (Chlamydia) (Trichomonas)___________________________
___Parasitic Infections______________________________________________________________________
___Strep Group A / Strep Group B____________________________________________________________
___Other___________________________________________________________________________________
Oncological:
___Cancer (give description & treatment) _____________________________________________________
___Benign Tumors & Cysts (give description & treatment) ______________________________________
Muscular & Skeletal:
___Spinal Disorders (describe)________________________________________________________________
___Osteoporosis____________________________________________________________________________
___Arthritis (Osteo Arthritis) (Rheumatoid Arthritis)______________________________________________
___Bone Fractures (Accidental) (Spontaneous)________________________________________________
___Orthodontic / Dental Disorders___________________________________________________________
___Tendonitis / Carpal Tunnel_______________________________________________________________
___Muscular Disorders / Cramps & Pain ______________________________________________________
___Severe Accident / Injury Trauma__________________________________________________________
___Other___________________________________________________________________________________
Reproductive:
___Ovarian Disorders_______________________________________________________________________
___Uterine Disorders_______________________________________________________________________
___DES Exposure (self) (mother)_____________________________________________________________
___Vaginal Infections (see list under STDs)___________________________________________________
___Menstrual Disorders_____________________________________________________________________
Pregnancy Related:
___Fertility Therapy_______________________________________________________________________
___Pregnancy Complication (describe)_______________________________________________________
___Miscarriages____________________________________________________________________________
___Medical Abortions_______________________________________________________________________
___D&C / D&E______________________________________________________________________________
___Birth Complications (describe)____________________________________________________________
___Caesarian Births (give reason)____________________________________________________________
___Multiple Births (twins) (triplets) (quads) (quints) (other)______________________________________
___Breech Births__________________________________________________________________________
___Premature Births_______________________________________________________________________
___Postmature Births______________________________________________________________________
___Stillborn (give reason)__________________________________________________________________
___Birth Defects (describe)_________________________________________________________________
___Other__________________________________________________________________________________
Nutritional & Dietary:
___Weight Disorders (Obesity) (Underweight)________________________________________________
___Eating Disorders (Anorexia) (Bulimia)___________________________________________________
___Dietary (describe special diet or nutritional requirements)________________________________
___Anemia (describe type)_________________________________________________________________
___Other (describe)_______________________________________________________________________
List any diagnostics & therapeutic treatments for any disorder: (Radiation) (CT Scan) (MRI) (EEG) (EKG) (Ultrasound) (Amniocentesis) (CVS) (Genetic Testing) (Surgeries):
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________


QUESTIONNAIRE FOR EXPECTANT MOTHER & HER PARTNER:
Please give some thought to the following questions and write your responses. Please be honest and open with your responses. This will give us something to discuss and allows me to "see where you are coming from", so to speak. . If you and your partner are together, each of you should give responses. Read all the questions before answering. If you need more space for your answers, please feel free to use the back side of this sheet for more room.
Why do you want to have this baby at home?_______________________________________________
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What do you see as the duties or responsibilities of your midwife?____________________________
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What do you think are the benefits of having a baby born at home?____________________________
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What do you think are the drawbacks of having a baby born at home?_________________________
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Please describe your previous birth experiences, if any. Were things done to you and/or your baby that you did not like, want or need? What would you change this time around? What are your partner's impression of the births?
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Do you have strong feelings about circumcision for male babies? If you are considering having this done, would you like more information about circumcision pros & cons?
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How do you feel about eye medications for your baby about an hour after the birth? Have they been previously explained to you? Do you feel they are necessary?
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How active of a role does your partner want to take in the birth of this baby? Labor support? Catching the baby? Cutting the cord?_______________________________________________________
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Are you and your partner both willing to obtain more education and do reading and use visual aids to obtain more information about pregnancy, childbirth, and parenting?
_________________________________________________________________________________________
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Do you feel you need some childbirth preparation for this birth? If so, what kind would you be interested in, if you have a preference?
_________________________________________________________________________________________
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What would you like your midwife to teach you specifically to prepare you and your partner for the birth?
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If you have children, how do you feel about having them present at the birth?
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There are some things which can complicate pregnancy, labor, birth, and afterward. If you are a low risk woman, the chances of unpredictable complications are low. However, if such complications should occur, you and your baby might be at greater risk because of being at home. There are risks involved with childbirth, no matter where the birth occurs, just as there are risks with driving a car, some of which will probably never be eradicated, no matter what our state of technology may be. There are certain risks involved with having your baby in a hospital, a birthing center, as well as your home. If you opt for a homebirth, you need to be aware of the risks (as well as the benefits) involved with this choice and how they may be handled. Please comment on what you know about risks and complications. How do you feel about them? What do you want to learn regarding risks and complications, including what you may be able to do to help the midwife prevent or reduce the risk of these things happening? Please include any questions or concerns you may have that you would like to discuss with your midwife.
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How do you think you might deal with the problem of a baby or mother who has suffered permanent injury or died at home? Again, this is very rare, but this does happen (much more frequently in a hospital than at home usually due to much lower intervention at home, but not always) and needs to be discussed.
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_________________________________________________________________________________________
_________________________________________________________________________________________
Your midwife knows her limitations in skill, knowledge, and in her practice guidelines. Many of these limitations are regulated by social, medical, and legal restraints. Are you willing to listen to and consider her suggestions, recommendations, and possibly a request to transport, if needed, for further medical care if a situation develops outside of her limitations?___________________________ If, after serious discussion of the situation, you decide to refuse transport to a medical facility, are you willing to sign a waiver/refusal to transport form?____________________________Have you faced opposition to your plans for a homebirth? _________ If, so, please describe?
_________________________________________________________________________________________
_________________________________________________________________________________________
How do your friends and family feel about your decision to have a homebirth?
_________________________________________________________________________________________
_________________________________________________________________________________________
Will you inform them of your decision?____________ Will any members of your family or your friends be present at the birth? _____________ If so, who?
_________________________________________________________________________________________
Are they willing to assist with needed chores & caretaking before, during and after the birth? _________________________________________________________________________________________
_________________________________________________________________________________________
If, so, what tasks will they be assigned?_____________________________________________________
Do you have postpartum care arranged?______________ With whom?___________________________
Names of relatives and/or friends that can be contacted quickly for additional help, if needed. Include their phone numbers.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Any other comments or information that you feel may be needed to be included in this registration form?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________





MoonDragon's Client Forms Index
MoonDragon Birthing Services - Holistic Homebirth Midwifery
MoonDragon's Pregnancy Information: Pregnancy Information & Survival Tips
MoonDragon's Pregnancy Information Index
MoonDragon's Womens Health Pregnancy Information Index
MoonDragon's Pediatric Information Index
MoonDragon's Parenting Information Index
MoonDragon's Nutrition Information Index






MoonDragon's Womens Health Index

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Health & Wellness Index





AROMATHERAPY: ESSENTIAL OILS DESCRIPTIONS & USES


Allspice Leaf Oil
Angelica Oil
Anise Oil
Baobab Oil
Basil Oil
Bay Laurel Oil
Bay Oil
Benzoin Oil
Bergamot Oil
Black Pepper Oil
Chamomile (German) Oil
Cajuput Oil
Calamus Oil
Camphor (White) Oil
Caraway Oil
Cardamom Oil
Carrot Seed Oil
Catnip Oil
Cedarwood Oil
Chamomile Oil
Cinnamon Oil
Citronella Oil
Clary-Sage Oil
Clove Oil
Coriander Oil
Cypress Oil
Dill Oil
Eucalyptus Oil
Fennel Oil
Fir Needle Oil
Frankincense Oil
Geranium Oil
German Chamomile Oil
Ginger Oil
Grapefruit Oil
Helichrysum Oil
Hyssop Oil
Iris-Root Oil
Jasmine Oil
Juniper Oil
Labdanum Oil
Lavender Oil
Lemon-Balm Oil
Lemongrass Oil
Lemon Oil
Lime Oil
Longleaf-Pine Oil
Mandarin Oil
Marjoram Oil
Mimosa Oil
Myrrh Oil
Myrtle Oil
Neroli Oil
Niaouli Oil
Nutmeg Oil
Orange Oil
Oregano Oil
Palmarosa Oil
Patchouli Oil
Peppermint Oil
Peru-Balsam Oil
Petitgrain Oil
Pine-Long Leaf Oil
Pine-Needle Oil
Pine-Swiss Oil
Rosemary Oil
Rose Oil
Rosewood Oil
Sage Oil
Sandalwood Oil
Savory Oil
Spearmint Oil
Spikenard Oil
Swiss-Pine Oil
Tangerine Oil
Tea-Tree Oil
Thyme Oil
Vanilla Oil
Verbena Oil
Vetiver Oil
Violet Oil
White-Camphor Oil
Yarrow Oil
Ylang-Ylang Oil
Aromatherapy
Healing Baths For Colds
Aromatherapy
Herbal Cleansers
Using Essential Oils


AROMATHERAPY: HERBAL & CARRIER OILS DESCRIPTIONS & USES


Almond, Sweet Oil
Apricot Kernel Oil
Argan Oil
Arnica Oil
Avocado Oil
Baobab Oil
Black Cumin Oil
Black Currant Oil
Black Seed Oil
Borage Seed Oil
Calendula Oil
Camelina Oil
Castor Oil
Coconut Oil
Comfrey Oil
Evening Primrose Oil
Flaxseed Oil
Grapeseed Oil
Hazelnut Oil
Hemp Seed Oil
Jojoba Oil
Kukui Nut Oil
Macadamia Nut Oil
Meadowfoam Seed Oil
Mullein Oil
Neem Oil
Olive Oil
Palm Oil
Plantain Oil
Plum Kernel Oil
Poke Root Oil
Pomegranate Seed Oil
Pumpkin Seed Oil
Rosehip Seed Oil
Safflower Oil
Sea Buckthorn Oil
Sesame Seed Oil
Shea Nut Oil
Soybean Oil
St. Johns Wort Oil
Sunflower Oil
Tamanu Oil
Vitamin E Oil
Wheat Germ Oil





HELPFUL RELATED MOONDRAGON NUTRITION BASICS LINKS

  • MoonDragon's Nutrition Basics Index
  • MoonDragon's Nutrition Basics: Amino Acids Index
  • MoonDragon's Nutrition Basics: Antioxidants Index
  • MoonDragon's Nutrition Basics: Enzymes Information
  • MoonDragon's Nutrition Basics: Herbs Index
  • MoonDragon's Nutrition Basics: Homeopathics Index
  • MoonDragon's Nutrition Basics: Hydrosols Index
  • MoonDragon's Nutrition Basics: Minerals Index
  • MoonDragon's Nutrition Basics: Mineral Introduction
  • MoonDragon's Nutrition Basics: Dietary & Cosmetic Supplements Index
  • MoonDragon's Nutrition Basics: Dietary Supplements Introduction
  • MoonDragon's Nutrition Basics: Specialty Supplements
  • MoonDragon's Nutrition Basics: Vitamins Index
  • MoonDragon's Nutrition Basics: Vitamins Introduction


  • NUTRITION BASICS ARTICLES

  • MoonDragon's Nutrition Basics: 4 Basic Nutrients
  • MoonDragon's Nutrition Basics: Avoid Foods That Contain Additives & Artificial Ingredients
  • MoonDragon's Nutrition Basics: Is Aspartame A Safe Sugar Substitute?
  • MoonDragon's Nutrition Basics: Guidelines For Selecting & Preparing Foods
  • MoonDragon's Nutrition Basics: Foods That Destroy
  • MoonDragon's Nutrition Basics: Foods That Heal
  • MoonDragon's Nutrition Basics: The Micronutrients: Vitamins & Minerals
  • MoonDragon's Nutrition Basics: Avoid Overcooking Your Foods
  • MoonDragon's Nutrition Basics: Phytochemicals
  • MoonDragon's Nutrition Basics: Increase Your Consumption of Raw Produce
  • MoonDragon's Nutrition Basics: Limit Your Use of Salt
  • MoonDragon's Nutrition Basics: Use Proper Cooking Utensils
  • MoonDragon's Nutrition Basics: Choosing The Best Water & Types of Water





  • RELATED MOONDRAGON HEALTH LINKS & INFORMATION

  • MoonDragon's Nutrition Information Index
  • MoonDragon's Nutritional Therapy Index
  • MoonDragon's Nutritional Analysis Index
  • MoonDragon's Nutritional Diet Index
  • MoonDragon's Nutritional Recipe Index
  • MoonDragon's Nutrition Therapy: Preparing Produce for Juicing
  • MoonDragon's Nutrition Information: Food Additives Index
  • MoonDragon's Nutrition Information: Food Safety Links
  • MoonDragon's Aromatherapy Index
  • MoonDragon's Aromatherapy Articles
  • MoonDragon's Aromatherapy For Back Pain
  • MoonDragon's Aromatherapy For Labor & Birth
  • MoonDragon's Aromatherapy Blending Chart
  • MoonDragon's Aromatherapy Essential Oil Details
  • MoonDragon's Aromatherapy Links
  • MoonDragon's Aromatherapy For Miscarriage
  • MoonDragon's Aromatherapy For Post Partum
  • MoonDragon's Aromatherapy For Childbearing
  • MoonDragon's Aromatherapy For Problems in Pregnancy & Birthing
  • MoonDragon's Aromatherapy Chart of Essential Oils #1
  • MoonDragon's Aromatherapy Chart of Essential Oils #2
  • MoonDragon's Aromatherapy Tips
  • MoonDragon's Aromatherapy Uses
  • MoonDragon's Alternative Health Index
  • MoonDragon's Alternative Health Information Overview
  • MoonDragon's Alternative Health Therapy Index
  • MoonDragon's Alternative Health: Touch & Movement Therapies Index
  • MoonDragon's Alternative Health Therapy: Touch & Movement: Aromatherapy
  • MoonDragon's Alternative Therapy: Touch & Movement - Massage Therapy
  • MoonDragon's Alternative Health: Therapeutic Massage
  • MoonDragon's Holistic Health Links Page 1
  • MoonDragon's Holistic Health Links Page 2
  • MoonDragon's Health & Wellness: Nutrition Basics Index
  • MoonDragon's Health & Wellness: Therapy Index
  • MoonDragon's Health & Wellness: Massage Therapy
  • MoonDragon's Health & Wellness: Hydrotherapy
  • MoonDragon's Health & Wellness: Pain Control Therapy
  • MoonDragon's Health & Wellness: Relaxation Therapy
  • MoonDragon's Health & Wellness: Steam Inhalation Therapy
  • MoonDragon's Health & Wellness: Therapy - Herbal Oils Index







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