Client's name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Client's email
*
Client's phone
*
(###)
###
####
Partner/support person's name
First Name
Last Name
Partner/support person's email
Partner/support person's phone
(###)
###
####
Emergency contact (name, relationship, phone number)
Estimated due date
MM
DD
YYYY
Care providers name
Birthing location (name of hospital, birthing center or home)
Have you taken a tour of your birth place?
Yes
No
I plan to.
It's my home.
Please list any allergies or food preferences that you have.
What number pregnancy is this for you?
How many previous births?
Please list the number of children you have and their ages.
How would you describe your previous births? (if applicable)
Think of birth and labor, write down the first 5-10 words that come to your mind.
What is your birth vision? If you had all of your wishes, how do you see laboring and giving birth? Do you have any strong preferences?
What do you think will be your greatest strength for your pregnancy/birth/postpartum experience?
What do you think will be your greatest challenge for this pregency/birth/postpartum experience?
Do you have any concerns/fears regarding your birth?
In previously emotionally or painfully intense situations (i.e. illness, losing a loved one, etc.), what have you found comforting?
In what ways do you hope a doula's support will be helpful for you? What types of assistance do you imagine will be useful for you? For your partner?
How does your partner/support person want to be involved in your birth? (i.e. hands on, share support with doula, or let the doula take the lead)
Are there any cultural/religious preferences that would influence your birth?
Do you drink/smoke/use drugs? If so, please explain the quantity/frequency before and during pregnancy and what you plan postpartum.
Please list any medical conditions prior to conception that would affect pregnancy or birth.
Please select any medical conditions that you have developed in pregnancy.
If other, please list here.
How much and how well are you sleeping during this pregnancy?
Please describe your physical and emotional prenatal and pregnancy experience thus far.
Have you taken, or are planning to take, a childbirth education class? Please list date(s) and location(s).
Please check any topics you would like to discuss with your doula.
Other topics you want to discuss?
Are you and/or your partner/support person reading books on pregnancy/childbirth/postpartum or breastfeeding? Please list below some resources that you have found helpful.
Have you written out your birth preferences? (If not, we can talk through this process and how best to communicate preferences with your medical providers.)
Have you shared your birth preferences with your medical provider?
Have you discussed protocols with your care provider if you go past your estimated due date?
During early labor, at what point do you want the doula to come to you? For example, do you want to labor at home with the doula or call upon the doula once you go to the hospital?
During early labor, when does your medical provider want you to call them?
Please describe any activities you have been doing to physically and emotionally prepare for your birth (i.e. yoga, meditation, exercise, etc.)
Have you packed a birth bag?
Please check any pain management techniques that you would like to use during your labor and birth.
Please list any other pain management techniques you would like to try.
Please check any early labor preferences that you have (these mostly apply to hosptial based births).
Please list other early labor preferences.
Please check any non-medical preferences in the hospital (or at home, if applicable).
Other non-medical preferences?
General Labor/Birth Preferences (select any and all that you are comfortable with and want to plan for)
Other labor/birth preferences?
How would you like your doula to respond if you are requesting pain medication?
If a hospital birth, please check your immediate postpartum preferences
Other postpartum preferences?
Do you have a pediatrician lined up?
How do you plan to feed your newborn?
If you are wanting to/interested in breastfeeding, have you contacted a lactation consultant?
Do you have a postpartum support plan?
Who is in your postpartum support team?
Please share anything else you would like me to know about you or any topics you would like to discuss?ea 20
Are you interested in placenta encapsulation services?
