Welcome to Footprints

I’m looking forward to improving your birth and postpartum experiences together! This form will allow me to better prepare and support you for the journey ahead. All information will be kept confidential.

Thank you for your time!

Your Name

First Name

Last Name

Your DOB

MM

DD

YYYY

Support Person Name

First Name

Last Name

Support person's relationship to you

Estimated Due Date (or date baby was born)

MM

DD

YYYY

Are you planning to have a vaginal or cesarean birth?

Where are you planning to give birth?

Who is your care provider?

Please specify speciality

Have there been any complications with this pregnancy/postpartum so far?

Have you had any previous C-sections?

If yes, please list the year and for what reason.

Have you had any previous miscarriages or stillbirths?

If yes, please write the stage of pregnancy and year.

Have you had any abortions?

If yes, please write the stage of pregnancy and year.

Please list any current medical/mental conditions you are being treated for and how they are being treated:

Is there anything else you'd like me to know about your health history, mental health, or personality?

Welcome to Footprints

You are not alone. ♡