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Birth Doula New Client Intake -Form Fill

Q1

First Name

Your Name*
Q2

Last Name

Your Name*
Q3

First Name

Your Partner's Name
Q4

Last Name

Your Partner's Name
Q5

First Name

Doctor/ Midwife's / Practice name*
Q6

Last Name

Doctor/ Midwife's / Practice name*
Q7

Hospital for Delivery*
Q8

Street Address

Address
Q9

Street Address Line 2

Address
Q10

City

Address
Q11

State / Province

Address
Q12

Postal / Zip Code

Address
Q13

Country

Address
Q14

E-mail
Q15

Phone Number

Home Phone*
Q16

Phone Number

Cellphone
Q17

Month

Estimated Due Date*
Q18

Day

Estimated Due Date*
Q19

Year

Estimated Due Date*
Q20

Baby's Gender
Q21

Baby's name (if known)
Q22

Planned Method of Feeding
Q23

Please state your general health
Q24

Do you have any allergies I should be aware of?
Q25

Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you, and any medications you are currently taking.*
Q26

Have you given birth before?*
Q27

Have you taken or are you planning on taking any childbirth education classes? If so, what are they and where are you attending them?
Q28

Please list any other classes you have taken or plan on attending.
Q29

Who do you plan to have assist you with your labor?*
Q30

Who do you want present for the delivery?*
Q31

Do you have a birth vision planned?
Q32

How do you feel about interventions in labor/delivery?
Q33

What type of pain management are you looking to have? *
Q34

What type of comfort measures would you like to use in labor?
Q35

What is your vision for this birth? *
Q36

What are your expectations of me as your doula?*
Q37

Do you have any cultural or religious rituals you'd like to present at your birth?
Q38

Are you a trauma survivor? If yes, are there any triggers I should be made aware of and are you comfortable with discussing them?
Q39

Any other questions or concerns?