S Certified Postpartum Questionnaire
Please take a few minutes to answer the questions below with as much detail as you're comfortable sharing. Your responses are completely optional and will help me better understand you, your family, and your goals, hopes, and expectations so I can best serve you.
Contact Information
First Name
*
Last Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Partner's First Name
Partner's Last Name
Partner's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Street Address
City
State
Zip Code
Are there any parking restrictions?
Yes
No
If yes, please explain.
Preferred Contact Method
Text
Phone Call
Email
Pregnancy & Birth Information
Estimated Due Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pediatrician
OB/Midwife
Hospital or Birth Center
Anything we should know about your pregnancy or birth?
History of anxiety or depression?
Yes
No
Prefer not to say
About Your Family
Baby's Name (if decided)
Are you taking maternity leave?
*
Yes
No
Is your partner taking leave?
*
Yes
No
Do you have other children?
*
Yes
No
If yes, names and ages
Do you have pets?
*
Yes
No
Any additional family information?
Infant Feeding
Feeding Method
*
Breastfeeding
Bottle Feeding
Combination Feeding
Exclusively Pumping
Undecided
Would you like information about feeding options?
*
Yes
No
Classes Attended
Infant CPR
Breastfeeding
Childbirth Education
Newborn Care
Other
Postpartum Support Goals
Support goals
*
Physical Recovery
Emotional Support
Breastfeeding Assistance
Infant Care Education
Overnight Support
Meal Preparation
Household Help
Rest
Newborn Routine Assistance
Sibling Support
Other
If Other, please explain
What specific areas would you like help with?
What helps you feel your best during postpartum?
Nutrition & Wellness
Dietary restrictions
Food allergies
Favorite meals
Foods to avoid
Pregnancy complications
Major life events or stressors
Cultural or religious traditions we'd like to honor
Baby Care
Do you use a baby tracking app?
*
Yes
No
Which app?
Would you like us to log feedings, diapers, and sleep?
*
Yes
No
Is there anything else you'd like your postpartum doula to know?
Submit
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