SS Doula Care Intake Form

Welcome Baby KC Birth Doula Services Intake Form

The information gathered from this form is for my eyes only, and is used as a tool so that I may better support you. You may skip any question(s) that you do not wish to answer. We will go over this sheet and the information at our prenatal visit(s).
Your Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Your Phone Number *

Area Code Phone Number
Your Email *
example@example.com
Occupation *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birth Partner's Name

First Name Last Name
Birth Partner's Phone Number

Area Code Phone Number
Birth Partner's Occupation
Preferred Method of Contact *

Text Email FaceTime Phone
Baby's Guess Date *

Year Month Day
Date
Name of Baby (if known)
Name of OB or Midwife *
Planned Birth Location *
Do you have other children? Names & Ages
Will they attend the birth?

Yes No Unsure at this time N/A
Pediatrician
Sex of Baby

Girl Boy Surprise! Twin Birth (Make note in separate box)
Will this baby be circumcised?

Yes No Unknown Please provide more information about the procedure
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? (i.e. Gestational diabetes, group B strep, etc.) As with all of your information, anything you share will be kept confidential. *
Have you seen any other care provider during this pregnancy? (i.e. acupuncturist, chiropractor, therapist, etc. *
Do you have any medical conditions or diseases that may affect my care for you? *
Have you ever had a LEEP procedure or any other cervical procedure? *
Have you ever been sexually or physically abused?
Do you have any questions or concerns about the care that you are receiving?
Have you talked about your birth preferences with your caregiver? Are there any cultural/religious choices/preferences for your birth that I should know about?
Do you have any allergies or special diet considerations?
This will help in the event that I bring snacks for you during labor.
Please explain how you typically cope with stressful or uncomfortable situations:
Is there any information about friends or family that may be involved in this birth that you wish for me to be aware of?
Is there anything else you want to share about your physical or emotional health related to your pregnancy and birth that will help me better serve you?
Have you taken or are you planning on taking any childbirth education classes? Which one(s) and where? *
Please list any other classes you have taken or plan on attending.
What are your hopes and expectations for this birth?
How can your Doula best assist you and your birth partner? Please include any requests for referrals or additional postpartum care
Is there anything else I should know in order to better support you?
Welcome Baby KC is collecting this information as it pertains to your case only. They will only share this information with a trusted partner & back-up doula, should it become necessary. Outside of that, they will never divulge your private information to anyone without your express consent.
Please sign in acknowledgement of the above.

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Welcome Baby KC Birth Doula Services Intake Form