Birth Doula Client Intake
Thank you for taking the time to fill out this form so I can get to know you better and have an idea of how I can best support you during your pregnancy, birth and postpartum.
Your Name*
First Name Last Name
Your Phone Number*
Country Code Area Code Phone Number
Your Birth Partner's Name
First Name Last Name
Your Birth Partner's Phone Number
Area Code Phone Number
Your Home Address*
Street
House Number
City State / Province
Postal / Zip Code
Your Email *
example@example.com
Your Birth Partner's Email
example@example.com
Current Pregnancy Information
Estimate Due Date*
Day Month Year
Date
Doctor/ Midwife's / Practice name*
Delivery Location
Home Birth Canter Hospital I'm not sure yet.
Address of delivery location if known:
Planned Method Of Feeding
Breastfeeding Formula Feeding Combination Not sure but I would like more information
Are you currently experiencing any specific health or other concerns that affect this pregnancy? As with all of your information, anything you share will be kept confidential.*
Explain any complications you have had with this pregnancy or any restrictions your caregiver has given you. *
Pregnancy History
Have you given birth before?*
No Yes, Vaginally only Yes, Cesarean Only Yes, Vaginally and Cesarean
Do you have a history of miscarriage or infant loss?
Yes No
Birth Preparation
Have you taken or are you planning on taking any childbirth education classes?*
Please list any other classes you have taken or plan on attending.
Who do you plan to have assist you with your labor?*
Partner/Spouse Doula Mother/Mother-In-Law Sister Friend
Have you written a birth plan?*
Yes, it is a final copy. Yes, but it is a draft and I would like some help. No, I would like like help writing one. No, I have no interest in one.
In 5 words, please describe how you would like to FEEL and how you would like your birthing space to feel? (ex: calm, peaceful, energized, happy)
Are there any cultural/religious choices/preferences for your birth that I should know about?
Have you talked about your birth preferences with your caregiver?
How do you feel about interventions in labor/delivery?
What type of pain management would you like to use?*
Comfort Measures IV Medication Epidural I'm not sure, I would like more information.
What type of comfort measures would you like to use in labor?*
Distractions Breathing Patterns Massage Birth Ball Walking, Dancing, Swaying Water (Tub/Shower) Hot/Cold Therapy Visualizations/Imagery Focal Points Aromatherapy (Essential Oils) Music
Please list any questions you have or topics you would like to discuss:
Should be Empty: