Consultation Questionnaire

We’re so glad you’re here.

This form helps us get to know you and your pregnancy a little better before your consultation.
All information is kept confidential and reviewed by our team with care.

Partner’s Name (if applicable)

Last Menstrual Period (LMP)

Was this a normal cycle?

Yes No

Estimated Due Date (EDD)

Current Weeks Gestation (if known)

Have you received care during this pregnancy?

Yes No

Have you had any ultrasounds?

Yes No

Are you currently taking any medications?

Yes No

If yes, please list medications

Any current concerns or conditions we should know about?

Do you have any past or current health issues we should be aware of?

Previous Pregnancies and Births

Total number of pregnancies (including current)

Number of live births

Number of miscarriages

Number of vaginal births

Number of cesarean births

How did you hear about us?

Who can we thank for referring you?

Is there anything else you’d like us to know before your consultation?

At Living Water Birth, we value informed, collaborative care. The information you share here helps us begin understanding your needs and how we can best support you.

Final eligibility for care is determined after your initial visit and review of your records (if applicable). If your care requires a different setting, we will always support you in finding the right fit.

Once you submit, we’ll review your information and reach out soon.

Address, City, State, Zip:

How did you learn about us?

Internet Search / Google Referred by a Friend Other

What has brought you to consider midwifery care and out-of-hospital birth for this pregnancy?

In the selection and screening of clients, we rely on medical history information provided by the client, and in some cases, information from previous healthcare providers.
A person asking to consider them for our care agrees that such information will be complete and accurate to the best of your knowledge; understanding that certain aspects of your health history may preclude you from midwifery care.
Even though we are meeting today, a final determination of "low risk" may not be made until the conclusion of the initial visit.
Please also note:

If you previously birthed by cesarean or have had uterine surgery, we must review the operative report prior to care.
If over 20 weeks gestation, we must review all current pregnancy records (including labs and ultrasound/s) prior to the start of care.
If transferring into our care at or after 30 weeks, we highly recommend that first-time parents attend childbirth classes and hire an experienced doula to be with you through labor, birth and the postpartum journey.

Have you received care this pregnancy?

Yes No

Are you currently taking any medications?

Yes No

Have you had an ultrasound/s?

Yes No

Any past or current health issues you feel we should know about?

Last menstrual period and/or conception date?

Was it a "normal" cycle?

Yes No

Due Date (EDD) if known

Current weeks gestation if known

How many total pregnancies have you had (including current pregnancy)?

Number of: Live Births

Please tell some basic Information about your previous pregnancies and births: (If you have had greater than 5 pregnancies, please complete this portion a second time.)

Name of child or type of loss

Month & year of birth

Baby's weight at birth

• If cesarean: reason

Medications in labor

Hospital / Birth Center / Home

Completed # of weeks at birth

• During the pregnancy

• During labor or birth

• Postpartum depression

We encourage you and your family to consider the following topics:

General health history questions
The risks and benefits of out of hospital birth to the mother and baby
Management of complications in an out-of-hospital setting
How labor and birth differ in a hospital
Your personal reasons for choosing out-of-hospital birth and midwifery care
LWB medical consultation arrangements and transport plan
Your ability to financially commit to client portion of practice fees

Consultation Questionnaire​

Consultation Questionnaire