Page 2 of 4 BIRTH PLACE & CARE PROVIDER Clinical Care Provider * First Name Last Name Provider's Phone Number * (###) ### #### Chosen Place for Birth * Home Hospital Birth Center Not sure yet Hospital or Birth Center (if applicable) HEALTH HISTORY Number of pregnancies, including this one: * 1 2 3 4 5 or more Have you experienced any of the following with a previous pregnancy? Spontaneous miscarriage/infant loss Elected abortion Preterm labor and birth Postdate ("late") birth General Medical History Do you currently have, or have you ever had, any of the following? Allergies Anemia Asthma Back injury Biopsy on cervix Bladder/kidney infection Cancer Eating disorders Gestational diabetes Gestational hypertension Group B strep High blood pressure HIV HPV Infertility Insulin-dependent diabetes Leep procedure PCOS Prior c-section Scoliosis General Psychological History Do you currently have, or have you ever had, any of the following? Abuse (any type) Addiction Anxiety/panic attacks Anxiety or mood disorder (any) Depression (treated or not) Fears (real or not) Personality disorder (any) Previous birth trauma PTSD Unusual pain/problems related to pregnancy If you checked any of the above, briefly describe here: Additional physical/psychological history: Any special dietary needs: Any nutritional supplements/vitamins you are currently taking: How often do you exercise, and what type(s)? Have you ever used, or are you currently using, any of the following? Alcohol Tobacco products Cannabis Prescription medications Non-prescription medications Herbal supplements Homeopathic remedies Aromatherapy If so, please describe: