Your Personal and Family Medical History

September 23rd 2009 -
Birth in the Tradition¢â
Personal & Family Medical History
Name___________________________ Date of Birth________________ Age____
National Origin___________
Partner¡¯s Name_____________________ Age__ National Origin ________________
Address___________________ City_____________ State____ Zip Code_________
Email Address______________________
Phone Number(s) Home___________________ Other________________________
Your Blood Type ____ RH______ Father¡¯s Blood Type____ RH____

Names & phone #¡¯s of significant support people:
1) Name __________________________
Ph #________________________________
2) Name __________________________
Ph #________________________________

Directions to your home: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for sharing this very personal information. It helps me get to know you and understand what¡¯s most important to you in a short period of time. This also helps me to vision how I may assist you best. All of the information remains confidential!

Whom may I thank for your referral? _________________________________

Your Story
Do you remember your first period?
Were you expecting it to arrive? What were your feelings at that moment?
Who prepared you for your first period?
How old were you when you first saw your period?
First day of last menstrual period___/___/___ (certain or estimate?)
Previous Menstrual Period ___/___/___ (certain or estimate?)
Was your last period normal?
Do you know when you conceived? If yes, give date ___/___/___
How long is your moon cycle? How many days do you flow?
Are your periods regular? How do you feel when you flow?
Do you have irregular cycles?
How many times have you been pregnant including now?
Have you ever had an abortion?
Please list date(s) and methods.

Do you feel at peace about the abortion(s)?

Have you had a miscarriage?

Please list dates, what occurred, and treatment if any.

Do you drink alcoholic beverages? What? How often?

Do you smoke cigarettes now? How often?

If you smoked cigarettes in the past, how long ago was it?

Do you smoke marijuana? How often?

Does your mate smoke cigarettes or use drugs?

Do you take any over -the- counter or prescription drugs? Why?
Please list:

If you have used illegal drugs in the 4 months prior to this conception, please list what and when.

Have you ever been hospitalized? Please list reasons and treatments.

Have you undergone therapy (medical or emotional, psychological) in the 4 months prior to conception?
List any medications used:

Have you ever experienced sexual abuse? If so, please describe.

Have you gotten past this experience?
Are you involved in a healthy relationship?
What is your marital status?
My concerns about labor, birth and/or becoming a parent are:

What is your vision for this birth?

Describe your mothers¡¯ birth experience. What about your sisters?

Are your relatives and friends supportive of homebirth? If not, how is this affecting you?

Part Two:
Your Prenatal Caring
Do you feel you are a good candidate for a home birth? Why or why not

How do you nurture yourself while you are pregnant?
Are you doing this to the best of your ability now?
Was this a planned pregnancy?
Is this a welcomed pregnancy?
Are you excited about being pregnant?
How do you generally take care of yourself when you are ill?
Do you nap during the day? Do you exercise? What kind and how often?
Do you spend time around volatile chemicals, paints, pesticides, smoke, etc..?
Do you have pets or animals that you tend to?
Are you knowledgeable of the use of herbs?
Do you use medicinal or beverage herbs?
Do you take vitamins or other supplements?
What are some of your religious, spiritual beliefs or philosophies?
Are there any practices you wish to include during pregnancy or birth?

Do you exercise? What types?

Are you on any restricted diet?
Live Foods____ Vegan ____ Vegetarian ____ Lacto Veg. ____ Lacto Ova _____
Do you plan to breastfeed? How long will you nurse this baby?
How does your mate feel about breastfeeding?
Do you plan to circumcise if you have a son?
Do you work outside the home? Describe your job.
How far into the pregnancy do you plan to work?
Will you return to work afterward?

Part Three:
Family Medical History
Please indicate any conditions pertaining to you or any family member. Indicate how this person is related to you, if you are not referring to yourself.
(M) mother, (MGM) maternal grandmother (MGF) maternal grandfather
(F) father, (PG paternal grandmother (PGF) paternal grandfather
(S) Self
Kidney Disease ¡à M ¡àMGM ¡àMGF ¡à F ¡àPGM ¡àPG

Diabetes ¡à M ¡àMGM ¡àMGF ¡à F ¡àPGM ¡àPGF

Epilepsy or Seizure Disorder ¡à M ¡àMGM ¡àMGF ¡à F ¡àPGM ¡àPGF

HeartDisease ¡à M ¡àMGM ¡àMGF ¡à F ¡àPGM ¡àPGF

Hypertension ¡à M ¡àMGM ¡àMGF ¡à F ¡àPGM ¡àPGF

Anemia ¡à M ¡àMGM ¡àMGF ¡à F ¡àPGM ¡àPGF

Phlebitis/Varicosities ¡à M ¡àMGM ¡àMGF ¡à F ¡àPGM ¡àPGF

Gastro Intestinal Problems ¡à M ¡àMGM ¡àMGF ¡à F ¡àPGM ¡àPGF

Sickle Cell Trait/Disease
¡à M ¡àMGM ¡àMGF ¡à F ¡àPGM ¡àPGF

Hepatitis or other Liver problems ¡à M ¡àMGM ¡àMGF ¡à F ¡àPGM ¡àPGF

Cancer ¡à M ¡àMGM ¡àMGF ¡à F ¡àPGM ¡àPGF
Downs+Syndrome ¡à M ¡àMGM ¡àMGF ¡à F ¡àPGM ¡àPGF
Emotional/Mental Health
¡à M ¡àMGM ¡àMGF ¡à F ¡àPGM ¡àPGF

Part Four: Prenatal Care
What was your pre-pregnancy weight? Blood Pressure? Hematocrit?
When did you first feel your baby move? Date___/___/___
Weeks pregnant_______?
Please list doctors, clinics or hospital where you have had prenatal care until now.

Do twins (or multiple births) run in your family?
During this pregnancy have you had x-rays, ultrasounds or amniocentesis?
List date and reasons:

Please circle any of the following complaints you have experienced during this pregnancy.
List dates and treatments:
Vaginal Infection
Sleep Disturbances
Visual problems
Urinary problems Dizziness/Fainting
Abdominal pain
Rapid Weight Gain
Constipation Heart Burn / Acid Reflux
Have you tested positive for any of the following during? List dates and treatment.
Urinary Tract Infections
Rubella (measles)
Other STD¡¯s
When was your last pap smear? Was it normal?
Have you ever had an abnormal pap?
If so, how was it treated?

Contact Member:
Birth in the Tradition/ Mother's Keeper

Atlanta, GA 30349
United States