Birth Client and Family Information

Client and Family Information

This form is for Sooner State Doula Birth Clients. Congratulations on your pregnancy! This will give me a better understanding of how I can best support you and your partner during pregnancy, birth, and postpartum. Thank you for taking the time to fill out this form. Please complete this form after signing your contract and paying your deposit. After this form is filled out I will be sending you the Sooner State Doula Client Workbook in the mail.

Family Information
Name

First NameLast Name
Partner / Birth Support's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Phone Number
Please enter a valid phone number.
Partner / Birth Support's Phone Number
Please enter a valid phone number.
Email
example@example.com
What is your preferred method of communication

Phone callTextEmail
Do you have any other children living in the home?
Please include their name and ages
Is there anyone else living inside the home? Do you have any pets?
What is your go to coffee/tea/smoothie order? Or favorite treat?

Health History
Please state your general health. Are there any chronic conditions that I should be aware of?
Do you (or anyone in your household) have any allergies to food, medications, body oils, essential oils or lotions that 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.
What is your previous experience with pregnancy/birth? Have you had children before? Have you watched anyone give birth?