Birth Report for Bradley Method Students (Natural Birth Prep with Nancy & George B)

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

George and I are delighted and blessed to have had a part in your preparation for your birth! If you've had your baby, even if we've heard from you already, please take a few minutes to fill out your birth report to help our organization have up to date records on birth outcomes for each year we have been teaching. We admit, we have been remiss in getting this information from some of you who have had your babies a while ago. Please help us get up to date for both the academy and ourselves as childbirth educators. This form is intended for all of our students, whatever kind of birth you had.

The results of this form are confidentially acquired and stored via google in our private googledrive.

If you are viewing this form in an email and prefer to fill the form out online, do so at: https://docs.google.com/forms/d/1kOZKGcl4702DMa0zE6lYc_TZFnnPs8wcZ69u6iMzQjs/viewform#start=invite

(If you clicked a link to get here, you are already on the webpage for the form.)

PART 1: CONFIDENTIAL BIRTH REPORT (required)
Please provide information regarding your birth. This information is required by American Academy of Husband-Coached Childbirth (AAHCC) to update their statistics. Click the check box for any detail you prefer to keep blank if you do not want to submit all of the information.

PART 2: RATING OF YOUR PREGNANCY/BIRTH TEAM (optional)
This information will help us recommend providers to our students, by giving us a clearer picture of what they offer, what they support, what they don't support, their bedside manner, etc, which is helpful when a student is in need of a new provider or other pregnancy/birth related service. This information is only used to help other students and your name is not provided. This is not passed on to AAHCC; only used by us to help our students.

PART 3: SHARE YOUR BIRTH STORY WITH US! (optional)
If you have not already done so, you may tell us your birth story and/or comments how our classes helped you with your birth for inclusion on our webpage(s) or for us to learn from. (This will not be submitted directly to AAHCC unless you click permission for us submit it for consideration to post on their birth story page at http://bradleybirth.com.) You may want to write this separately and then copy and paste into the form, or email it to us if desired.

PART 4 (required): Please give or deny permission to share your birth story or opinions of your providers. We will not disclose your name to anyone but simply pass along your experience or comments.

PART 5 Tell us if you would like information about any upcoming reunions we may plan for our students and/or if you would like to come to a current or upcoming series to share your birth story.

We would also like to know if you are interested in becoming a Bradley instructor/doula. If so, I recommend you also send me an email to let me know you are interested as it may be some time before I review your report.

Thanks in advance for helping us update our records!

Email *

PART 1: Confidential Brief Birth Report for AAHCC

(required)

Class Date (First Day of Series) *

If you are unsure, just indicate month and year you started the series with us.

Mother's First & Last Name *

Father's First & Last Name *

Permission for use of full names in the report (preferred by AAHCC) *

Yes

No, please use our first names and last initial(s) only

Other:

Address *

Address (2)

City *

State *

Zip Code *

Permission to submit Full Address (preferred by AAHCC) *

(AAHCC does not share your contact information.)

Yes, ok to submit

Do not include our street address to AAHCC

Other:

Email Address *

example: me@mymail.com

Email Permission

(AAHCC does not share your contact information)

Please do not give AAHCC my email address.

Other

Baby's Date of Birth *

Baby's gender/ Name *

Part of a Multiple Birth

(include baby's or babies' genders and names in other)

Yes

Other:

Birth Place

(hospital, birth center, out-of-hospital birth center, home, etc.)

Length of gestation (pregnancy) in weeks

Labor

Spontaneous

Induced

Augmented

None

Other:

Clear selection

Birth *

Check all that apply

Vaginal

Forceps

Vacuum

Cesarean

VBAC

Fetal death

Maternal death

Other:

Required

Birth Attendant *

Doctor

CNM

Licensed Midwife

Lay Midwife

Other:

Required

Drugs for Pain *

(You may specify types in other if desired, i.e., Demerol, epidural, lidocaine, novacaine)

None

For Labor

For Delivery

For Repair

Other:

Required

PART 2: RATE YOUR HEALTH CARE TEAM (optional)

Please share your evaluations and comments/suggestions about your health care team. You can use the text boxes to write details such as the following:

1. Name & area(s) of expertise
2. Location of practice/office or community serving
3. Your opinion of the services provided or any other info you think would be of interest to prospective clients from our classes.

Or if you prefer, you can skip the individual questions and rate your providers with a scale though this is not as helpful for providing recommendations.

Primary Pregnancy/Birth Provider