Julia Carmen Doula Services Intake Form

Julia Carmen Doula Services Intake Form

Please fill out this confidential form so that I may best serve you
Your Name

First NameLast Name
Partner's Name (if applicable)

First NameLast Name
Any additional partners or significant support people?
Estimated Due Date ("Guess Date")

MonthDayYear
Date
Your Date of Birth

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parking instructions
Your Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Partner's Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Your Email
example@example.com
Partner's Email (if applicable)
example@example.com
Your Occupation or how do you spend most of your time?
Partner's Occupation (if applicable)
How did you hear about me?
Please list any previous children and their ages, or write none
Sex of baby (if known)
Name of baby (optional)
Care Provider (OB or Midwife Name)
Planned Birth Location
Number of previous pregnancies
Any pregnancy losses?
Any abortions?
Please describe details of your previous pregnancies, labor, and births, or write none.
Did you have any medical complications with any previous pregnancies? If so, please describe here.
Have you had any medical complications with this pregnancy (e.g., gestational diabetes, IUGR, breech baby, anemia, hypertension, low lying placenta)?
Please describe the details of any breast procedures you have had, no matter how minor.
Please describe the details of any fertility treatments used to conceive this pregnancy.
Do you currently have any sexually transmitted infections?
Please describe the details of any mental health issues that you have had and how they were treated.
Please describe the details of any mental health issues that your partner has had and how they were treated.
Have you or any of your close female relatives suffered from a postpartum mood disorder?
Have you had any major emotional, physical, or sexual trauma in your past?
If so, do you wish to share or discuss what happened either here or in person?
Please describe in detail any other major medical events or conditions that you have experienced (e.g., broken bones, surgeries, dental issues, major illnesses).
Do you or anyone else in your household smoke?
Have you used alcohol or recreational drugs during this pregnancy?
Are you taking childbirth education, infant care, or breastfeeding classes? If so, where?
How is your sleep currently?
Please describe things you have used in the past to cope with sleep issues.
How is your diet currently?
What (if anything) do you feel like you could improve about your eating habits?
Do you currently have any major life stressors such as financial, legal, marital, or familial health issues?
Are you currently seeing a therapist?
How prepared do you feel for parenthood?

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9

10

1 is Not at all prepared, 10 is Very prepared
How prepared do you feel for your birth?

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10

1 is Not at all prepared, 10 is Very prepared
How do you plan to feed your baby?

Other
Do you plan to use pain medication during your labor?
How would you characterize your relationship with your care provider?
Have you discussed your preferences for your birth with your care provider?
Is there anything else that you wish to discuss or are concerned about?
Should be Empty: