Language
English (US)
Client Intake Form
Please answer all questions to the best of your ability. If there are questions you don’t want to answer, please remember you do not have to. The information you give will help me provide more comprehensive services to you. I respect your right to privacy and can assure that your answers will be held in the strictest confidence. With your permission, I may potentially share this intake form and any drafted birth plans with my backup doula should they need to support you in my absence.
Contact Information
Full Name:
*
First Name
Last Name
Partner's Name (if applicable):
First Name
Last Name
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
-
Area Code
Phone Number
Partner's Phone Number (if applicable):
-
Area Code
Phone Number
E-Mail Address:
*
example@example.com
Preferred contact method:
Phone
Text
Email
Emergency Contact (name and phone number):
This Pregnancy
Expected Due Date:
*
-
Month
-
Day
Year
Date
Baby's Sex:
*
Girl
Boy
Don't Know
Baby's Pediatrician (name and phone number):
If you have not picked one yet, just leave blank.
Doctor / Midwife:
*
Planned Place of Birth:
*
Did you select this provider specifically for this pregnancy?
Yes
No
Are you comfortable with your provider?
Have you discussed any questions, concerns, or wishes with your OB/Midwife? If so, are you comfortable with the responses you receive?
Do your providers know you are planning on having a birth doula?
Yes
No
Have you taken a tour of your birth facility? If not, do you plan to?
Have you taken any childbirth and/or breastfeeding classes? If not, do you plan to?
Are you seeing any wellness practitioners (chiropractor, acupuncture, etc.)?
Was this a planned pregnancy?
Any difficulty conceiving? Any special technology used?
Any ultrasounds/prenatal tests? (Amino, Glucose, Group B Strep, etc.)
Any medical complications with this pregnancy?
Personal History
Check all that apply:
Diabetes
Preeclampsia
High Blood Pressure
Heart Problems
Herpes
STD
Group B Strep
Placenta Previa
Breech Presentation
Substance Abuse
Depression
Anxiety
Any prior procedures/surgeries?
How many times have you conceived? Any miscarriages or abortions?
Birth History (if applicable):
Have you ever breastfed? Any issues?
About You
Age:
Profession / Occupation:
Who else lives in your household? (If any children, please list names and ages):
Which best describes your current personal fitness level?
Daily exercise
Exercise at least 2x week
Occasional aerobic activity (walking/running/swimming/yoga, etc.)
Low activity level
Any dietary restrictions or on a modified diet?
Which term describes you best?
Introvert
Extrovert
In general, where do you feel tension during times of stress? (head, neck, jaw, shoulders, etc.)
What do you find comforting during times of stress? (e.g. solitude, companionship, distraction, etc.)
How would you describe your relationship with your partner? (if applicable)
Birth Planning
Given that the birthing person and baby are healthy and doing well, what are your top three priorities for this labor and birth? (e.g. respect, choices, calm environment, minimal interventions, etc.)
What is your vision for this birth?
What is your current plan for coping with labor and preferences for pain management?
How do you think a doula will be helpful to you / what are your expectations of your doula?
What are some expectations/worries you have of your partner (if applicable)?
Do you (or your partner) have any concerns regarding labor or childbirth (even if it is a "minor" thing)?
What coping techniques do you expect might be helpful during labor?
Coached Breathing
Hypnobirthing methods
Birth Ball
Massage
Heat
Hydrotherapy (bath/shower)
Moving Around/Changing Positions
Verbal Encouragement
Affirmations/Mantras
Visual Imagery
Music
Quiet Environment
Aromatherapy
TENS Unit
What things do you definitely NOT want during labor/childbirth?
Will anyone else be attending your birth (family member, photographer, etc.)?
How do you and your partner feel about having an intern/resident present during labor and/or birth?
Are you planning on taking labor and/or childbirth photos?
Yes
No
Will you be keeping your placenta after the birth?
Yes
No
What are your postpartum support plans (if any)?
Any cultural or religious traditions/beliefs you wish to honor during labor or childbirth that I should be aware of?
Any special concerns you have (ex. about taking care of a newborn, breastfeeding, pain management, postpartum, etc.?
Anything else you would like me to know so that I can better support you?
How did you hear about us?
*
Doulamatch.net
Referral / Word of Mouth
Google search
Internet
SUBMIT
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