Congratulations on your pregnancy! Thank you for taking the time to fill out this form so I can get to know you better and have an idea of how I can best support you during your pregnancy, birth and postpartum. Please answer each question to the best of your ability. Feel free to omit any information you wish not to share with me. I commit to keeping your personal information confidential.
Your Name
*
First Name
Last Name
Pronouns
*
Your Birthdate
*
-
Month
-
Day
Year
Date
Age
*
Your Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Phone Number
*
Format: (000) 000-0000.
Your Email
*
example@example.com
Calls, texts or emails preferred?
*
Partner
*
I'm a single parent by choice
The father is not involved
I have a partner involved
Other
Your Birth Partners Name
First Name
Last Name
Relationship (Boyfriend or husband for example)
Your Birth Partner's Phone Number
Format: (000) 000-0000.
Your Birth Partner's Email
example@example.com
Emergency Contact Name
*
First Name
Last Name
Relationship?
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Pregnancy Information
Estimate Due Date
*
-
Year
-
Month
Day
Date
Doctor/ Midwife's / Practice name
*
Delivery Location / Name of Hospital or Birth Center
*
Home, Birth Center, Hospital
Do you know what the sex of your baby is?
*
Boy
Girl
Waiting to find out!
Do have a name or names picked out?
This is baby number:
*
This is a
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Singleton
Twin
Triplet
Other
Do you have a history of miscarriage or stillbirth?
*
yes
no
Have you received fertility treatments? If yes, which one and how long?
Have you ever had a C-section?
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Yes
No
If yes, for what reason(s) and how long ago?
Have you given birth before?
*
No
Yes, Vaginally only
Yes, Cesarean Only
Yes, Vaginally and Cesarean
Female/Menstration Health History (that could affect pregnancy/birth)
*
Endometriosis
PCOS
Heavy Periods
Painful Periods
BRCA Gene
Cancer
Depression
Anxiety
Other Mental Health Issues
Hypertension (High Blood Pressure)
Diabetes
Fibromyalgia
Heartburn
Hepatitis B
Kidney Disease
IBS
Heart/Cardiac Issues
Sleep Apnea
STI/STDs
Chronic Pink Eye
Allergies to essential oils or honey?
Nothing... I am in good health.
Other
Other (please specify)
Pregnancy related problems so far?
*
Gestational Diabetes
Preeclampsia
Breech
Placenta Previa
GBS + (if known)
IUGR
Short Cervix
Cervical cerclage
History of Preterm Labor
Nothing! This is a complication free pregnancy.
Other
Other (please specify)
Are you currently experiencing any specific health or other concerns that affect this pregnancy? As with all of your information, anything you share will be kept confidential.
*
Do you currently see any of the following practitioners:
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Chiropractor
Pelvic Floor PTf
Physiotherapist
Acupuncturist
Aroma Therapist
Acupressure
Massage
Dietician/Nutritionist
Naturopath
Psychologist
Psychiatrist
None
Other
Other (please specify)
Planned Method Of Feeding
*
Breastfeeding
Formula Feeding
Combination
Not sure but I would like more information
Explain any complications you have had with this pregnancy or any restrictions your caregiver has given you.
*
Tell me about you!
What do you and your partner or a friend do for work and what do you do in your spare time? Anything else I should know about you? Any animals in your life?
*
What's your favorite TV show or movie?
*
Have you taken or are you planning on taking any childbirth education classes?
*
Please list any other classes you have taken or plan on attending.
*
Who do you plan on having in the room during labor?
*
Partner/Spouse
Mother/Mother-In-Law
Sister
Friend
Other
Who do you want present for the delivery?
*
Do you have a birth (plan) vision planned?
*
Yes, it is a final copy.
Yes, but it is a draft and I would like some help.
No, I would like like help writing one.
No, I have no interest in one.
In 5 words, please describe how you would like to FEEL and how you would like your birthing space to feel? (ex: calm, peaceful, energized, happy)
*
Tell me what you like to see in your birth space? Pretend you are standing at the door of your room looking in (and you have a clear view into the bathroom)... what do you see? (candles, affirmations or pictures hanging up, favorite water bottle, ect.)
*
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?
*
How do you feel about interventions in labor/delivery? How would you like your doula to respond if you are requesting pain medication?
*
What type of pain management are you looking to use?
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Comfort Measures
IV Medication
Epidural
Nitrous Oxide (laughing gas)
No pain medication/plan to go unmedicated
Other
What type of comfort measures would you like to use in labor? (list as much/many as you'd like).
*
Distractions
Breathing Patterns
Hypnosis
Mediation
Massage
Birth Ball
Walking, Dancing, Swaying
Water (Tub/Shower)
Hot/Cold Therapy
Visualizations/Imagery
Focal Points
Aromatherapy (Essential Oils)
Music
Other
Other (please specify)
When you are in pain what types of personal comforts do you like to use? Eg. A quiet room, dimlighting, heat, cold, words of affirmation, etc.
*
What is your vision for this birth?
*
What are your feelings about labour and delivery?
*
What is your biggest fear about labor and delivery?
*
What kinds of sounds and smells are comforting to you?
*
What phrases help you feel powerful? Either when spoken to you or when you say them toyourself?
*
Where do you usually hold tension in your body?
*
How would you most like to be supported during labour?
*
Anything else I should know in order to better support you?
*
Insurance and Benefits
Do you plan on claiming birth doula support on your benefits/insurance plan?
*
Yes
No
Would you like to use HSA/FSA?
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Yes
No
Is there anything else you need in order to claim birth doula support in any way? (please specify)
*
Do you think insurance should cover doula services (including birth, postpartum and sibling doulas)?
*
Yes
No
I'm not sure
Birth Photo, Video & Media Release
I/we, the client(s), agree to the following (check all that apply):
*
I would like photographs to be taken.
I would like video to be taken.
I would like photos/video taken:
*
during labor
during birth
after birth
of the baby
I would like to use (can choose more then one option)
*
my camera
his camera
intended parents camara
my doula's phone (we use our phones to take photos, send you the photos before we leave, then delete the photos from all devices.
my doula uses her fancy camera
Preferences surrounding graphic/intimate photos:
*
No intimate or graphic photos, please
Upper half is ok, but I don't want pictures of my lower genitals
I don't mind intimate or graphic photos being taken tastfully
Please check the box (which means you Initial it) to indicate your understanding each of the following:
*
I understand that policies at my birthing facility may forbid video or photos to be taken at certain times. I understand that itis my responsibility to negotiate the photo/video policy with facility staff, not my Doula's.
I give permission to my Doula to use photos of me and my baby in printed materials. (Each photo will be subject to your approval, and your permission may be revoked at any time.)
I give permission for my Doula to use photos of me and my baby on her website or online social media. (Each photo will be subject to your approval, and your permission may be revoked at any time.)
I understand that photography and video are not my Doula's main focus in the birth space.
As your Doula, I am committed to keeping your personal information private and will not under any circumstances share that information with anyone. I respect your family's privacy and right to announce the long-awaited arrival of your baby,and will not share any type of announcement without your express permission.
This birth photography and video release form has been reviewed and agreed to by the following the birthing person/mom on this form, as designated by their signature below:
*
Last question.. what is your favorite affirmation? (birth or otherwise).
*
Thank you SO much for taking the time to fill this questionnaire. Knowledge is power, so the more I know about you, the better I can help you. I am looking forward to your beautiful birth. You are going to do awesome! Don't forget to let me know about how your appointments go. I am here for you... whatever you need even if it's just a cry or vent. Text or call anytime!
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