Consultation Form

Consultation Form
Name

First NameLast Name
Your Partner's Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Partner's Number
Please enter a valid phone number.
Address

Street Address

Mailing Address

CityProvince

Postal / Zip Code
Your Birth Date

MonthDayYear
Date
Your Baby's Due Date

MonthDayYear
Date
Where are you planning on giving birth?
Select any of the following that are applicable to you:

Trouble SleepingSinus ConditionSkin ConditionPast SurgeriesFrequent HeadachesSerious HeadachesArthritisPast serious illnessHeart ConditionPast Serious AccidentHypoglycemicDiabeticAllergiesBlood PressureAsthmaInfectious DiseaseOsteoporosisCancerOther serious illnessChronic Fatique
Select if you have or had any problems with the following:

EndocrineImmune & LymphaticRespiratoryUrinaryMuscular-SkeletalNervousCardiovascularDigestiveReproductiveOther
Name of Doctor/Midwife & phone #
Is this your first pregnancy?
Number of previous pregnancies
Number of births
Have you had any preterm births? What was the cause?
Have you had a previous C-Section? What was the cause?
Have you had any miscarriages? At how many weeks?
Please describe any current health problems you have
Are you currently taking any medications? Please list all of them
Is there anything else about you or your health that you would like to share?
Do you or have you had any mental health issues? Please describe.
What is your occupation?
On a scale of 1-10 what is your stress level at?
On a scale of 1-10 what is your level of physical daily activity?
Is this the same as before you were pregnant? Or an increase/decease?
How many oz of water are you drinking daily?
Since finding out you were pregnant, have you been practicing healthy habits (avoiding drugs, alcohol, careful with caffeine, eating adequately, etc)? Please describe.
What was your reason for wanting a doula?
Regarding labour and delivery what is your biggest concern/fear?
Regarding postpartum, what are your concerns/worries?
How do you plan on feeding your baby? Formula? Breast? Bottle? Both?
Have you taken any childbirth education classes? Please name and briefly list some topics that were taught (breastfeeding, comfort techniques, medical interventions, etc.).
Is there anything else you feel I should know about you or your families?
Do you have additional support besides your partner? Please list them.
One a scale of 1-10 how involved does your partner want to be through labour and delivery. 1 being they'll be in the room, 10 being they want to see baby coming out.
Who would be your emergency contact (if partner is unavailable)? Name and phone #.
What are you most excited for?
Are there any specific questions you have for me? And/or are there any specific topics you'd like to discuss or have more information on?
Thank you!
Should be Empty:

Consultation Form

Thank you!