Language
English (US)
Class Registration Form
Instructor- Michelle Smith
About You
First Name
*
Last Name
*
Age
*
Occupation
*
Phone
*
E-mail
*
About Your Birth Partner
Partner's First Name
*
Partner's Last Name
*
Partner's Age
*
Partner's Occupation
*
Partner's Phone
Your Address
Street
*
City
*
State
*
Zip Code
*
About Baby
Do you know if you are expecting a boy or a girl?
*
Surprise
Girl
Boy
Baby's Name, if chosen and you would like to share it?
Names and ages of baby's siblings, if any?
*
Pregnancy Related Medical History
Some of this information is sensitive by nature. Please know that I honor that. Thank you for sharing your answers with me as you feel comfortable. It allows me to do my best to support you fully and cater our classes according to your unique experiences and needs.
Estimated Due Date
*
Date of Last Menstrual Period, if known
*
Number of pregnancies including this one
*
1
2
3
4
5
6
7
8
9
10
OB or Midwife
*
Where do you plan to give birth?
*
Home
Inspiration Birth Center
Tree of life Birth Center
The Birth Place
Heart 2 Heart Birth Center
Advent Health- Altamonte
Advent Health- Orlando
Advent Health- Winter Park
Advent Heath- Celebration
Winnie Palmer Hospital
Central Florida Regional
Oviedo Medical Center
Any Miscarriages or Abortions?
*
no
yes
If yes, type of loss and when?
early perinatal loss history
Any Stillbirths?
*
no
yes
If yes, when?
perinatal loss 20 weeks or after
Was this pregnancy the result of fertility treatments?
*
N/A
this pregnancy
previous pregnancy or pregnancies
became pregnant while taking a break from treatment
fertility drugs
IUI
IVF
Are there any medical concerns for this pregnancy?
*
no
yes
If yes, please explain:
medical concerns or conditions
Do you have a history of trauma or abuse?
*
N/A
childhood
adult
physical
emotional
sexual
previous traumatic birth experience
Are you experiencing any recurrent stress during this pregnancy?
*
no
yes
If yes, please explain:
experience of stress or anxiety
Are you using the any of the following complementary birth services during your pregnancy?
*
N/A
chiropractic care
acupuncture
craniosacral therapy
yoga
doula services
counselling or therapy
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If this is not your first pregnancy, please describe your previous pregnancies and birth experiences:
*
Additional Information
What prompted you to choose this method of childbirth education?
What is most important to you during our class time together?
*
Any previous or concurrent childbirth birth education classes?
*
no
yes
undecided
If yes:
Date, Type, and Location
Please describe your ideal birth experience:
*
Do you have any fears or concerns regarding pregnancy and birth?
*
Are your friends and family supportive of your birthing plans? If not, what are their concerns?
*
Do you have any religious, cultural, philosophical, or spiritual beliefs that you would like me to be aware of or that you would like me to help you to honor?
Are you interested in any of the following Birth Ease Services?
*
N/A
undecided
placenta encapsulation
doula services
Any additional comments, questions, or concerns?
Birth Ease Class Enrollment Agreement
*This Course contains the opinions and ideas of its author. It is intended to provide helpful and informative material on the subjects addressed in the course. Upon submitting this enrollment form, it is understood that the authors and publishers are not engaged in rendering medical, health, or any other kind of professional services in this course. The enrollee should consult with their medical, health, or any other competent professional before adopting any of the suggestions in this Course or drawing inferences from it. The enrollee is aware that they are to seek the advice of their medical or licensed health care provider regarding any health, obstetric, or pediatric issues or concerns. The enrollee also understands that every pregnancy, labor, birth and postpartum period is unique, and that attending this course does not guarantee a specific outcome at anytime during the childbearing year. This course contains guided relaxation recordings and techniques. The enrollee understands that everyone's experience with the techniques is unique and will vary. The enrollee agrees to be guided through relaxation, creative visualization, and stress reduction processes and techniques. The enrollee fully acknowledges that they must avoid listening to the guided relaxation recordings while engaging in an activity that requires their full attention. The enrollee understands that they must be certain that they are safely seated or reclining in a supported position while utilizing the relaxation techniques and recordings. Unless the enrollee is the passenger listening to one of the guided relaxation recordings with headphones on, for everyone’s safety the enrollee must never listen to any of the recordings while driving or riding in a car. The authors and publishers disclaim all responsibility for any liability, loss, or risk, personal or otherwise, which is incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this Course.
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*
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*
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