The information provided herein is supplied by several sources and is subject to change without notice.  Niza Rodriguez  does not guarantee or is any way responsible for its accuracy, and provides said information without warranties of any
kind, either express or implied. 2009 Niza Rodriguez All Rights Reserved.
Chose the following topics that affect your choices for childbirth
Choice of Birth Attendants
Choice of Birth Locations
Importance of Atmosphere
Level of Involvement In Care
View of Childbirth
Would chose the following
comfort techniques if available
Household Income
Choice of Payment
Would you chose a freestanding birth center with a homelike
atmosphere, run by a trained staff of nurses and a CNM, located
close to a hospital that offers a self-pay package?
NO
YES
NEEDS ASSESSMENT
Your Name:
Occupation:
E-mail:
Phone Number:
Partner's Name:
Age:
Address:
HEALTH ASSESSMENT
Please list any allergies or illnesses (chronic or otherwise)
Please list any prenatal testing and results.
Please list any medications (supplements) that you are
currently taking.
Please list any complications or restrictions from previous
pregnancies.
Totals number of previous pregnancies?
Totals number of previous Miscarriages?
Totals number of previous Stillbirths?
Total number of previous abortions?
Vaginal or Cesarean births?
Most recent birth?
Smallest/largest baby?
 Gender?
To
PREPARATION FOR BIRTH
Have you taken childbirth classes? Please explain the philosophy?
Are you preparing a birth plan or need assistance in this area?
What is your philosophy toward medical interventions including
medications?
List way you typically cope with stressful or painful situations?
Which comfort measure do you wish to try during labor? (check all that apply)
Hot/cold therapy
Massage/counter pressure
 Labor tub
Shower
Rocking Chair
Walking
 Birth Ball
Squatting
Distracting activities
Music
Breathing patterns
 Vocalization
Other:
Focal Point
Prayer/Scriptur
Questions, Comments, or Feedback
Dear Friend,
The following form is a survey of women's health needs for those between the ages of 18-45 as it relates to
needs during childbearing years. Any woman can fill this out and DOES NOT  have to be pregnant. I am
currently in the process of writing a business plan to start a free-standing birth center here in Coshocton and
need this information to develop a marketing strategy to reach those interested in this kind of service. It will be
available to anyone (low-risk) that wants to have their baby in a home-like atmosphere with a CNM (Certified
Nurse Midwife) and team of nurses and aides. Complete prenatal care, delivery, recovery, postpartum and
newborn screening will be available and kept at a cost efficient self-pay price around two thousand nine
hundred ninety nine dollars ($2,999). I am in the process of looking for board members that view this opportunity
as a Faith-Based Ministry.  If you know of anyone interested in making this happen, either through practical
leadership abilities or financial assistance. (After the submit button you will see a page with all contact
information).
Thank you again for any help in distributing this info, and for prayer support, that with God's Blessing will make
this become.

God Bless!

Terri Phillips RN, BSN Administrator
E-Mail: Terri_Phillips@nizarodriguez-sells4u.com                         Click  here for more Info.
Please fill out the following survey and click submit
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welcome to:
2360 sqft  $158,900
3480 Sqft  $324,900
MLS: 3010656
3480 Sqft  $324,900
MLS: 3041154
3 Bedrooms $44,500
MLS: 3056202
NIZA RODRIGUEZ
REAL LIVING THE RIGHT CHOICE
711 Walnut St Coshocton, OH
Direct: 740-502-7560
Email: getitsold27@yahoo.com
web: www.nizarodriguez-sells4u.com