Your Name
*
First Name
Last Name
Estimated Due Date
*
MM
DD
YYYY
Care Providers Name or Practice
First Name
Last Name
Labor Companion
First Name
Last Name
Additional Companions
Any other person that will be in the room. i.e. photographer, doula, sister, etc.
Labor:
Check any and all that apply.
Labor Notes:
Add any additional requests/comments.
Mobility:
Check any and all that apply.
Mobility Notes:
Add any additional requests/comments.
Hydration + Nourishment
Check any and all that apply.
Hydration + Nourishment Notes:
Add any additional requests/comments.
Monitoring:
Check any and all that apply.
Monitoring Notes:
Add any additional requests/comments.
Pain Relief: Non-medical Options
Check any and all that apply.
Pain Relief: Non-medical Options Notes:
Add any additional requests/comments.
Pain Relief: Medical Options
Check any and all that apply.
Pain Relief: Medical Options Notes:
Add any additional requests/comments.
Augmentation: If my labor slows down, I would...
Check any and all that apply.
Augmentation Notes:
Add any additional requests/comments.
Pushing:
Check any and all that apply.
Pushing Notes:
Add any additional requests/comments.
Birth + Baby Care
Check all that may apply.
Birth + Baby Care Notes:
Add any additional requests/comments.
I would like _________ to cut the cord.
In Case of a Cesarean I would like _____ to accompany me during surgery.
In case of a Cesarean:
Check all that may apply.
