Birth Report for Bradley Method Students (Natural Birth Prep with Nancy & George B)
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 prefer to fill the form out online, do so at: https://docs.google.com/forms/d/1kOZKGcl4702DMa0zE6lYc_TZFnnPs8wcZ69u6iMzQjs/viewform#start=invite

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.

Thanks in advance for helping us update our records!

Email address *
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.
Your answer
Mother's First & Last Name *
Your answer
Father's First & Last Name *
Your answer
Permission for use of full names in the report (preferred by AAHCC) *
Address *
Your answer
Address (2)
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Permission to submit Full Address (preferred by AAHCC) *
(AAHCC does not share your contact information.)
Email Address *
example: me@mymail.com
Your answer
Email Permission
(AAHCC does not share your contact information)
Baby's Date of Birth *
Your answer
Baby's gender/ Name *
Your answer
Part of a Multiple Birth
(include baby's or babies' genders and names in other)
Birth Place
(hospital, birth center, out-of-hospital birth center, home, etc.)
Your answer
Length of gestation (pregnancy) in weeks
Your answer
Labor
Birth *
Check all that apply
Required
Birth Attendant *
Drugs for Pain *
(You may specify types in other if desired, i.e., Demerol, epidural, lidocaine, novacaine)
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
(Name, area of exertise, location, opinion &/or comments)
Your answer
Birth Assistant (if applicable)
(Name, area of exertise, location, opinion &/or comments)
Your answer
Primary Nurse (if applicable)
(Name, area of exertise, location, opinion &/or comments)
Your answer
Doula
(Name, area of exertise, location, opinion &/or comments)
Your answer
Lactation Consultant
(Name, area of exertise, location, opinion &/or comments)
Your answer
Pediatrician/Pediatric Nurse Practitioner
(Name, area of exertise, location, opinion &/or comments)
Your answer
Place of Birth
(Name, area of exertise, location, opinion &/or comments)
Your answer
Your Childbirth Educator(s)
(Opinion &/or comments about how our classes specifically helped you with your pregnancy/birth/postpartum. We may use your positive comments without identifying you for our website or other means of publicity. Constructive criticism also welcomed, but we recommend you use the official evaluation form from class 11/12 or the via email or webpage version for specifics about each of our classes.)
Your answer
Other:
Your answer
Quickly Rate Your Health Care Team
You may also quickly rate your providers, though your own comments above will be most meaninful for us to be able to recommend your favorites to others.
Not Applicable
Very Dissatisfied
Somewhat Dissatisfied
Neutral
Satisfied
Very Satisfied
Other
Primary Pregnancy/Birth Provider
Birth Assistant if any
Primary nurse (if any)
Doula (if applicable)
Lactation consultant
Pediatrician or Pediatric Nurse Practitioner
Place of Birth
Your Childbirth Educators
Other (specify in comments box above this ratings table.)
PART 3: BIRTH STORY & COMMENTS, RECOMMENDATIONS (optional)
This portion is optional, though we love to receive your stories and suggestions! Your identity will be protected if any of your story, comments or suggestions in our classes. You can give permissions for ue otherwise below in the PERMISSIONS section.]
If desired, please write (or copy and paste) your birth story and/or comments about our classes and how they helped you below (if not indicated in PART 3.)
Your answer
PART 4: PERMISSIONS regarding your birth story
Please check all applicable below regarding your birth story, including how you would like to be identified (i.e., full name, first names only, initials, city & state ok, or not ok, etc.)
PART 5 Final questions
Would you like to meet up again?
Just One More Question... Are you interested in become a Bradley certified childbirth educator/doula?
You are done! Thank-you very much!
If you have any questions or additional comments, please contact Nancy via email: naturalbirthprep@yahoo.com .

Click the button to submit. You may edit your answers if something needs changing.

Thank-you very much for your particiipation in the Bradley Birth Survey and our optional birth story and comments section.

Nancy & George

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