Doula Client Intake Form

Congrats on your pregnancy! I am excited to work with you. This intake will help serve your needs more fully. Take your time filling this form in. Some of the questions are there to bring up questions that you might have that perhaps you hadn't thought of yet. There are no wrong answers. It's a get-to-know-you and intake combined into one! Make sure to jot down your questions. Let's get them answered.
Todays Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your Name
Estimated Due Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referral From
Your Address
Your Email
example@example.com
Your Cell
Your DOB
Your Age
Your Profession
Birth Partners Name
Address if different from your address
Partners Email
example@example.com
Partners Cell
Partners Profession
Babys Name
Do you know the gender of your baby
First Day of your last menstrual period
Date of Conception

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Pregnancy Number
Can you tell me about your prior birth experiences if you have had a baby before
Any Medical History of note with THIS pregnancy:
If you could describe your DREAM BIRTH what would it be like
Is there any medical history that might pertain to this pregnancy? (Cesarean, LEEP, Trauma, or other experiences that you want to share with me that may affect your labor pattern)
Who will be in the birth room with you
Are there people that you do not want to be in the birth room
Do you like to be touched or massaged
What things would not be comforting (i.e. smells, sounds)
Would you like more information regarding:
What Childbirth education classes have you taken or are you planning to take
What sort of exercise do you get
How do you feel about epidurals and comfort management
How do you see the role of your partner
Would you like more information regarding:

Other
Do you have questions regarding a Birth Plan or Birth Wishes?
Jot down any questions that you might have. We will take time to get them all answered.
Birthing Location
Care Providers Name
Name of Care Providers Practice
Care Providers Office Number
Should be Empty: