Consultation Form
Name
First Name
Last Name
Your Partner's Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Partner's Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Mailing Address
City
Province
Postal / Zip Code
Your Birth Date
-
Month
-
Day
Year
Date
Your Baby's Due Date
-
Month
-
Day
Year
Date
Where are you planning on giving birth?
Select any of the following that are applicable to you:
Trouble Sleeping
Sinus Condition
Skin Condition
Past Surgeries
Frequent Headaches
Serious Headaches
Arthritis
Past serious illness
Heart Condition
Past Serious Accident
Hypoglycemic
Diabetic
Allergies
Blood Pressure
Asthma
Infectious Disease
Osteoporosis
Cancer
Other serious illness
Chronic Fatique
Select if you have or had any problems with the following:
Endocrine
Immune & Lymphatic
Respiratory
Urinary
Muscular-Skeletal
Nervous
Cardiovascular
Digestive
Reproductive
Other
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!
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