Name
*
First Name
Last Name
Partner's Name
First Name
Last Name
Doula Preference?
No Preference
Alanna
Khristina
Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Phone
(###)
###
####
Partner's Email
Partner's Phone
(###)
###
####
Your Birthday
MM
DD
YYYY
How did you hear about us?
Google
Facebook
Instagram
Referral
Other
If referral or other, please describe:
Who is your medical provider in terms of your pregnancy or fertility care?
Type of Provider?
Midwife
Doctor/OBGYN
Undecided
Where do you plan to give birth?
What is the address and/or name of the facility you plan to give birth at? If you are planning to deliver at a birth center or at home, please specify your backup hospital (name, city/state):
Do you have any allergies we should be aware of? If yes, please describe:
Have you had any recent illnesses, surgery, injuries or accidents that you wish to share with us? If yes, please describe:
Do you currently take any prescription or non-prescription medications that you want us to be aware of? If yes, please describe:
Have you had any periods of mental illness, depression, anxiety disorder or previous postpartum depression that you wish to share with us?
Explain anything else you would like us to know about your health condition:
How many times have you been pregnant (including current pregnancy):
How many times have you given birth?
How many of your pregnancies have been carried to term (born after 37wks)?
How many of your pregnancies were preterm (born between 24-37wks)?
How many of your other births ended before 24wks?
How long did your previous labor last?
How many children do you have?
Have you given birth to multiples?
Have you placed any children for adoption?
Have you adopted any children?
Which types of births have you experienced? (Select all that apply)
Have you had any of the following pregnancy-related health conditions in PAST pregnancies?
Please tell us anything else you might like us to know about your past pregnancies:
Baby's Due Date
MM
DD
YYYY
Are you expecting multiples? (Twins, triplets, etc.)
What type of birth are you planning?
How do you plan to birth?
Please list any pregnancy related health conditions you've had in your current pregnancy:
Describe what your ideal birth would be:
Do you think labor will hurt?
Are you afraid of the idea of pain in relation to birth?
How do you ordinarily deal with pain? How do you see yourself coping during labor?
Do you have any fears of this birth?
Rate how much you would like or not like each of the following to occur during your childbirth experience:
Stripping Membranes
Induced Labor
Pitocin Augmentation
Artificial Rupture of Membranes
Wearing a hospital gown
Having a saline lock
Having an IV
Not being allowed to eat or drink
Being confined to the bed
Narcotic pain meds
Epidural
Urinary Catheter
Continuous external fetal monitoring
Internal fetal scalp monitoring
Pushing on your back
Episiotomy
Perineal Tear
Vacuum-assisted or forceps delivery
Cesarean Birth
Immediate cord clamping
Immediate skin-to-skin contact
Delay newborn exam procedures
Cord traction
Deep suctioning of baby's airways
Antibiotic Ointment in baby's eyes
Vitamin K injection (baby)
Hep B injection (baby)
Keeping your placenta
Baby being bathed shortly after birth
Circumcision
Please describe the role you envision for your doula at your birth:
Who else will be at the birth and what role would you like them to play?
Is there anyone you do NOT want to be at the birth or in the immediate postpartum period?
What would your partner like your doula to do to help them be more supportive during labor?
Do you have any religious or cultural beliefs that you would like us to be aware of?
Do you feel safe?
Comments or questions?
