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

Date

Your Name

Estimated Due Date

Date

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

Date

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:

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