CRITICAL ALLERGIES OR CONDITIONS
[Add any severe allergies, reactions, or medical emergencies here]
Personal Information
Name
[Your name]
Date of Birth
[DOB]
OB/Midwife
[Provider name and clinic/hospital]
Medical History
Allergies
[List any drug allergies, latex sensitivity, etc.]
Chronic Conditions
[Any ongoing health conditions]
Current Medications
[Medications you're taking, even supplements]
This Pregnancy
Due Date
[Your due date]
Important Concerns
[Gestational diabetes, high BP, previous loss, etc.]
Preferences to Know
[Pain management preferences, movement preferences, who should be present]
Your Support Team
Partner/Support Person
[Name and role]
Emergency Contact
[Name and phone]
Who to Call if Something is Wrong
[Provider phone number, hospital main line]
Birth Preferences
How I Handle Pain
[Your preferences and what helps you]
What I Want After Birth
[Skin-to-skin, delayed cord clamping, etc.]
Things I Want to Avoid
[Interventions you want to discuss first]
Quick Reference
Last menstrual period: [Date]
Estimated weeks: [# weeks]
Insurance: [Policy and member ID]