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Brit Milah Questionnaire
Please fill out the following survey after you have delivered your baby boy. Please provide as much detail as you are able and feel free to leave anything blank that you do not know the answer to.
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Caregiver #1: Name, relationship, and religion
*
Your answer
Caregiver #2: Name, relationship, and religion
Your answer
Date and time of birth (ex: 5/22 at 3:09AM)
*
Your answer
Did your baby receive his vitamin K shot?
*
Yes
No
Do you belong to a temple? If so, which temple? If not, are you interested in joining one?
Your answer
Do you have a rabbi you would like me to work with when planning your child's brit milah?
Yes
No
Clear selection
Does either biological parent have any family history of bleeding or clotting disorders? (Examples: hemophilia, von Willebrand, factor deficiency). If so, please state which disorder and who has it.
Your answer
Where will the ceremony be held? (ex: your home, synagogue, a party center)
Your answer
Who will be your Sandek (traditionally male, does not need to be) and how are they related to the baby. *This is the person that will hold the baby during the procedure. Must be able to tolerate the site of blood*
Your answer
Who will be your Kvatar (person who brings the baby out at the beginning of the ceremony, people often select a baby's grandparents)
Your answer
Who will help offer the baby the wine soaked cloth to provide comfort during the ceremony?
Your answer
Are there any other people you want to honor during the ceremony? If so, we can discuss other ways to have them involved.
Your answer
Are there specific questions you would like me to address when we talk?
Your answer
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