Request for Midwifery Care
Pregnant Mother's Name *
Your answer
Mobile Phone Number *
Your answer
Email Address *
Your answer
Date of Last Menstrual Period *
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YYYY
Due Date if Known *
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DD
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YYYY
Father's Name *
Your answer
Will Father Attend the Birth? *
How did you hear about Midwife Aisha Al Hajjar? *
Your answer
Have you started prenatal care with another provider? *
What reason do you want to change providers? *
Your answer
Names and relationships of all persons you would like to attend your birth. *
Your answer
What are your religious preferences? *
Your answer
Number of prior pregnancies? *
Your answer
Number of prior births? *
Your answer
Have you ever had a home birth before? *
Why are you considering home birth now? *
Your answer
Have you ever attended childbirth education classes? *
Have you had prior cesarean births or uterine surgeries? (Note that Delaware regulations do not allow home births in this case.) *
What medications are you taking and for what? *
Your answer
Do you smoke, currently drink alcohol, or use illicit drugs? (Note Aisha's policy does not allow home birth for these situations.) *
Do you have any specific questions or special concerns? *
Your answer
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