Today’s Date__________

Name________________________ Coach’s name_________________

Desired Series: (see class schedule page) ____________________________
Address/Phone____________________________________________
E-Mail________________________ Approximate Due Date__________
Birth Attendant____________________________________________
Birth Location _____________________________________________
Any Children? ____________________________________________
Names/Ages______________________________________________

How would you describe your diet?
_______________________________________________________

Does mom smoke?______ If so, how much?__________ Is she exposed to
smoke?  _________________________________________________

Have there been any medical problems with this pregnancy?
_______________________________________________________
_______________________________________________________

Were there any complications with any previous pregnancies or births?
_______________________________________________________
_______________________________________________________

Assuming a “normal” labor, would you like to strive for a natural birth?  If so,
why?___________________________________________________

Have you discussed your wishes/expectations for labor/birth with your
provider yet?_____________________________________________

Were they supportive?
_______________________________________________________

Do you plan to breastfeed?___________   If  no, why?
_______________________________________________________

What do you hope to gain from this class?
_______________________________________________________
_______________________________________________________
_______________________________________________________

What are your main concerns regarding labor and birth?
_______________________________________________________
_______________________________________________________
_______________________________________________________

Class Location:  1249 Viking Dr South, Arnold, MD 21012
Time:  6:30 PM- 9:00 PM
Fee:  $275.00     Deposit:  $75.00

Painting by Mara Friedman