Postpartum Questionnaire for Parents Postpartum Questionare Name: Partner: Address: City State/Province Zip/Postal Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe 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?