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Step 1 of 6:
Visit Information
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Reason for visit:
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Maternity
Antenatal Testing
Maternity Information
First baby?
Yes
No
Single or multiple babies expected?
Single
Multiple
Pediatrician:
Primary/Family physician:
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Obstetrician's/Midwife's name (if a group practice, please provide names of obstetricians/midwives):
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First day of last menstrual period:
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Maternity due date:
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Specify the Inova Women's Center location you have chosen for your maternity care:
Inova Alexandria Hospital Women's Center
Inova Fairfax Hospital Women's Center
Inova Fair Oaks Hospital Women's Center
Inova Loudoun Hospital Women's Center/The Birthing Inn
Birthing Options
Prenatal
Have you attended childbirth education classes?
Yes
No
I would like information regarding maternity tours.
Yes
No
Labor support person:
Did your labor support person attend classes with you?
Yes
No
Children
Do you plan to have your children visit immediately after birth?
Yes
No
Will they visit you and your new baby during your hospital stay?
Yes
No
Are you considering having your child(ren) present for the birth?
Yes
No
If yes, who will chaperone? (Children must be accompanied by an adult other than the parent)
Note: We offer a sibling class to prepare children for a new baby.
Birth
After discussion with your healthcare provider, which of the following delivery methods are you planning to use? (Check all that apply)
Lamaze techniques
Epidural anesthesia (IV necessary)
Cesarean-section
VBAC (Vaginal Birth After Cesarean)
Newborn
Pediatrician name:
Pediatrician phone:
Do you plan to breastfeed?
Yes
No
If your baby is male, do you plan to have him circumcised?
Yes
No
Hospital Stay
Do you have any special dietary needs? If so, please describe.
Religious preference?
Yes
No
Specify religious preference:
Going Home
Have you made arrangements for help at home?
Yes
No
Special Needs
Has your obstetrician/midwife indicated that you or your baby may have special needs related to this pregnancy? If so, please explain.
Are you or your companion deaf?
Yes
No
Are you or your companion hard of hearing?
Yes
No
Do you want to communicate with your caregivers in a language other than English? Specify language:
Do you require an onsite interpreter?
Yes
No
Specify interpreter language:
Do you require communication aids during your visit?
Yes
No
Specify communication aids needed:
select
ASL Interpreter
Signed English Interpreter
Oral Interpreter
Video Remote Interpreter
TTY/TDD
Assistive listening device
Telephone handset amplifier with flasher
Closed captioning in patient room
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