AMANI Birth Student Birth Record
Please keep us informed of your students’ birth statistics
Mother’s Student Number *
Your answer
Mother’s Name *
Your answer
Baby’s name: *
Your answer
Birthdate: *
Please enter in DD/MM/YYYY format.
Your answer
Weight and length: *
Your answer
Birthplace (home, hospital, birth center): *
Attended by Obstetrician, Midwife, Unassisted: *
Did you have anyone to support you during your birth? *
Check all that apply.
Required
Were any medications used for birth? *
Mark all that apply
Required
Was labor spontaneous, induced, or sped up? *
How was birth accomplished? *
Was an episiotomy given? *
Were stitches required after birth? *
Tell us how the AMANI class prepared you her for birth. *
Please enter her words.
Your answer
How many classes were in her series? *
Did she attend all 20 modules?
Did her husband attend any classes with her?
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