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 Name
Last Name
Partner / Birth Support's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / 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 call
Text
Email
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?
Pregnancy Information
What number pregnancy is this for you?
What number birth?
When is your estimated due date?
-
Month
-
Day
Year
Date
What is your OB/ Midwife's name?
Where are you planning to give birth?
Is your care provider aware that you will be using a doula?
Baby's gender?
Please Select
Boy
Girl
Unknown
Baby's name? (If you would like to share!)
Planned method of feeding?
Please Select
Breastfeeding
Exclusively pumping
Formula feeding
Combination of the above methods
Not sure, I could use some more information before I choose!
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?
Birth Preparations
Have you taken/taking/planning to take any childbirth education classes, read any books, or listened to any podcasts? If so, what are they?
Please provide the name and relation (to you) of those you plan to have with you during the labor and birth process.
Do you have a written birth plan / preferences?
Please Select
Yes, it is finalized!
Yes, but I would like some help reviewing it.
Kind of, it is still in my head!
No, I would like some help writing one!
No, I am not interested in one.
Would you like information or resources for any of the following?
Mental Health Services
Birth Education / Prep
Lactation Care
Prenatal Exercise
Prenatal Nutrition
Chiropractic
Pelvic Floor Physical Therapy
An OBGYN/Midwife/Birth Location to fit my goals
Postpartum Doula
Circumcision
Overnight Postpartum Doula or Professional Sleep Consultant
Placenta Encapsulation
Pediatrician or Family Doctor for my baby
List of Sooner State Doula lending library options
Car Seat Safety / CPST
Cloth Diapering
Other
Have you had any recent major changes in your life (family/friend death, a recent move, job change)?
Sometimes traumatic past experiences can influence the course of labor. As your doula, I value your whole experience as a person - everything that has made you to be the incredible person you are today. I will consider everything I know about you to offer you the most helpful support during labor. Is there anything else you would like me to know about you that may affect your birth?
Is there anything on your mind right now that you want your doula to know?
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