Postpartum Questionnaire for Parents

Postpartum Questionare

Name: *

Partner:

Address: *

Address:

City

State/Province

Zip/Postal

Country

Phone: *

Cell Phone: *

Email: *

Preferred method of contact: *

Names/ages of other children:

Name of Care Provider:

Where do you plan to give birth?

Due Date

Is this your first pregnancy/birth?

Do you plan to receive medication during labor?

Do you plan a vaginal or cesarean delivery?

Have you taken a childbirth or breastfeeding class?

Will you circumcise a male baby? If so, when?

Any cultural/religious or family traditions to be observed?

How would you describe your pregnancy?

Who will be helping you at home after birth? For how long?

Have you experienced any major changes in the past 12 months (moved, changed jobs, had a family death, etc.)?

Have you read any books or magazines on parenting/baby care? Which ones do you like/dislike?

What aspect of parenting/baby care concerns you the most?

Have you cared for an infant before?

Do you plan to breastfeed, formula feed, pump and bottle feed, or a combination?

Where will your baby sleep for the first two months?

Are you currently employed? Do you plan to return to work after the baby is born? What are your plans for feeding/childcare at that time?

Do you have a history of depression? Are you currently on anti-depressant medication?

Who else is likely to be working in your home at the same time that we will be helping you?

Is there anything else that you would like to tell us about yourself or your family?

What is your basic household schedule? (Meal times, naptime, bedtime for children etc.)

Are there food allergies in your household? *

If you are human, leave this field blank.