Birth Doula Intake Form
Congratulations on your pregnancy! Thank you for booking me as your doula. I am excited to support you through this process. Please fill out this form and send it back to me. It’s okay if you don’t know all the answers. If it’s all too much, we can fill it out together at your first prenatal visit. Please just send me your contact information! Note: I am fully vaccinated, including all COVID boosters and the yearly flu vaccine.
Your Info
Name
First Name
Last Name
Phone number
Please enter a valid phone number.
Email
example@example.com
Your due date
-
Month
-
Day
Year
Date
Your home address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pronouns preferred
she/her
he/him
they/them
Other
Your preferred method of communication
email
text
phone call
Other
Your Partner's Info
(if applicable)
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Pronouns Preferred
she/her
he/him
they/them
Other
Prenatal Information
Who is looking after your medical care?
Midwife
Obstetrician
Undecided (family doctor for now)
Other
Name of medical provider (including name of practice)
Phone number of medical provider
Please enter a valid phone number.
Are you considered high risk? If so, what makes you high risk?
Do you have any mental health struggles? If so, has pregnancy made any difference?
If you have been pregnant before, what was the outcome?
Never been pregnant before
Loss
Termination
Cesarean
Vaginal delivery
If you have experienced loss, I’m so sorry. Is there anything specific that I can do to hold space for you? Would you like to talk about it, or would you rather not reference it if possible?
Do you have any health conditions that concern you or your provider?
Do you have any health conditions that concern you or your provider?
Do you want pain relief during labour?
Yes
No
Wait and See
Other
Do you plan on birthing at home or at a hospital?
Home
Hospital
Other
Please provide your planned hospital for delivery, if applicable.
How do you feel about other interventions? (Pitocin, IV fluids, doctor breaking your water, etc). Note: pitocin can often be avoided to induce labour but may still be used after delivery if you are hemorrhaging, as an emergency measure.
What are your feelings on the possibility of needing an unplanned cesarean section?
Do you have a birth plan? If not, would you like my help to make one?
If planning on a hospital birth, do you want to labour at home for as long as possible, or would you prefer to go to the hospital as early as you can?
Regarding labour and delivery, describe your greatest fear.
Regarding labour and delivery, describe your partner’s greatest fear. (If applicable)
Who will be at your birth, aside from you, me, and medical staff?
Rate your worst period cramps from 1-10, 1 being no pain at all, 10 being absolute agony.
How do you normally cope with period pain, aside from medication?
What are your expectations for your doula during labour?
What comfort measures do you think you’ll like? Indicate as many as you like. You can change your mind during labour!
Aromatherapy
Dancing/Swaying
Walking
Distractions
Music
Breathing Patterns
Massage
Water (bath/shower/birthing tub)
Birth ball
Visualization/Imagery/Guided meditation
Heat/Cold
Other
Would you like me to take photos of your labour and birth? (Only if/when it does not distract from comfort measures)
Yes
No
Undecided
Do you have a preferred position to push/give birth in?
Squat
Laying on side
All Fours
Laying on back
Whatever works
Other
Postpartum
If you have pets, please indicate their species and how they react to strangers.
Do you have any allergies or dietary restrictions?
Do you have a name picked out for your baby, that you would like to share?
Planned method of feeding:
Breast/Chestfeeding
Pumping
Formula
Combo Feeding (breast and formula)
Unsure/Would like more info on feeding methods
Other
What are your favourite meals and snacks?
Do you have any other questions or concerns? Feel free to write as much as you need to.
Submit
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