Doula Intake Form

Congratulations on your pregnancy! 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 NameLast Name

Your Partner's Name

First NameLast Name

Doctor/ Midwife's / Practice name*

First NameLast Name

Hospital for Delivery*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

example@example.com

Home Phone*

Cellphone

About your baby

Estimated Due Date*

MonthDayYear

Baby's Gender

BoyGirlUnknown

Baby's name (if known)

Planned Method of Feeding

BreastfeedingFormula FeedingBothNot sure but would like more information

About your health

Please state your general health

Do you have any allergies I should be aware of?

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

Preperation for Birth

Have you given birth before?*

NoYes,Vaginally onlyYes, Cesarean onlyYes,Vaginally and Cesarean

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

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

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

Who do you want present for the delivery?*

Do you have a birth vision planned?

Yes, It is a final copyYes, but it is a draft and would like some helpNo, I would like some help writing one.No, I have no interest in one.

How do you feel about interventions in labor/delivery?

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

Comfort MeasuresIV MedicationEpiduralOther

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

What is your vision for this birth? *

What are your expectations of me as your doula?*

Any other questions or concerns?

The Essential Element