Vragenformulier
Vul alle vragen uitgebreid en naar waarheid in.
Name
*
Voornaam
Achternaam
Partner
Voornaam
Achternaam
Dierenarts
*
Naam
Plaats
E-mail
*
Telefoonnummer
*
-
Tweede telefoonnummer
-
Gegevens van jouw hond
Naam van jouw hond
*
Geboortedatum
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
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2016
2015
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2012
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1929
1928
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1926
1925
1924
1923
1922
1921
1920
Year
Geslacht hond
*
Reu
Teel
Gecastreerd/ gesteriliseerd
Planned Method of Feeding
Breastfeeding
Formula Feeding
Both
Not sure but would like more information
About your health
Door wie ben je doorverwezen of getipt?
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?
*
No
Yes,Vaginally only
Yes, Cesarean only
Yes,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?
*
Partner
Doula
Mother/ Mother-in-Law
Sister
Friend
Other
Who do you want present for the delivery?
*
Do you have a birth vision planned?
Yes, It is a final copy
Yes, but it is a draft and would like some help
No, 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 Measures
IV Medication
Epidural
Other
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
Visualization/Imagery
Focal Points
Aromatherapy
Music
What is your vision for this birth?
*
What are your expectations of me as your doula?
*
Any other questions or concerns?
Submit
Should be Empty: