Name *

First Name

Last Name

Have you been happy with your chosen birth place so far? *

Very happy and excited

Seems great so far

Have had a few concerns

I've been thinking of changing

Have you been happy with your OB or Midwife practice so far? *

Very Happy and have loved everyone I've met so far

No problems with anyone so far, but haven't connected with anyone on a deep level yet

I may have had a red flag or two with a OB or Midwife

I am fairly concerned at this point in my pregnancy that my philosophy might not match well with the OB or Midwife practice I am currently with

Where do you fall on the Penny Simkin pain medication preference scale? *

+10: Wants to feel nothing; desire anesthesia before labor begins.

+9: Fear of pain; lack of confidence that I will be able to cope; dependence on staff for pain relief.

+7: Definite desire for anesthesia as soon in labor as the doctor will allow it, or before labor becomes painful.

+5: Desire for epidural anesthesia in active labor (4-6cm); willingness to cope until then, perhaps with narcotic medications.

+3: Desire to use some pain medication, but wants as little as possible; plans to use self-help comfort measures for part of labor.

0: No opinion or preference.

-3: Prefers that pain medication be avoided, but wants medication as soon as requested in labor.

-5: Strong preference to avoid pain medications, mainly for benefit to baby and labor progress. Will accept medications for difficult or long labor.

-7: Very strong desire for natural childbirth, for sense of personal gratification as well as to benefit baby and labor progress. Will be disappointed if I use medications.

-9: Wants medication to be denied by staff, even if I ask for it.

-10: Wants no medication, even for cesarean delivery.

Birth Partner Name

First Name

Last Name