Postpartum Client Intake
Questionnaire
Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Hospital or Home?
OBGYN/Midwife/Doula
How was your baby born?
Vaginal with epidural/pain medication
VBAC
C-Section
Vaginal with no epidural/pain medication
Please list any medical/health concerns you have experienced throughout pregnancy or postpartum if any
Do you have a support system and plan set up for postpartum?
Yes
No
If so, list below.
Help me to know what areas you may need extra support
latching baby
Milk production
Pumping
Sibling support
Light Household Tasks
Light Meal Prep
Birth Processing
Newborn Care How To
Overnight Support
Sleep Support and Strategy
Care for baby while you rest
Other
Are you taking parental leave? If so, how long? Is your partner taking parental leave? If so for how long?
How many days per week are you hoping to have doula support? Are there specific days you’d want to request?
What time of day do you foresee needing/wanting support?
Are there any parenting techniques or style that you plan to use, or that you have questions about?
Please let me know your goals for feeding baby or babies
Exclusive Breastfeeding
Formula
Pump to Bottle
Mixture
What are your primary goals for having a Postpartum Doula?
Rate your sleep quality in the last 5 days on a scale from 1-10 with 1 being the worst ever and 10 being the very best
Are you experiencing PPMD (postpartum mood disorders) and if so, can you explain some of the feelings and thoughts you’ve been having? No judgement whatsoever!
How did you hear about my services?
Are there any other services you are interested in?
Postpartum Ceremonies
Newborn Photos
Herbal Support
Placenta Encapsulation
Other
Anything else you would like to add?
Submit
Should be Empty: