Client Intake Form
A Dove's Love
Client Information
Name:
First Name
Last Name
Age:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State:
Phone #
Format: (000) 000-0000.
PARTNER'S INFORMATION
Partner's Name:
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State:
Phone #
Format: (000) 000-0000.
How did you hear about my services?
BIRTH PREFERENCES
Do you know the sex of your baby?
Girl
Boy
Do you have a name for your baby?
Yes
No
How many weeks are you?
Expected delivery date?
Do you have a primary attendant chosen for your birth?
Undecided
am hiring a (non-medical) Birth Attendant
Registered Midwife
Family Physician
Obstetrician
Other
Provider name
Where are you planning to give birth?
Undecided
Home
Hospital
Birth Center
Other
Organization's name
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BIRTH Preferences
Do you plan to give birth:
Naturally (comfort measures/no pain medication)?
With an Epidural
Other pain medication
C-Section
Induced
Other
Who all do you want in your delivery room?
What is the full extent of medical intervention that you want?
Current pregnancy history: Have you been diagnosed with any of the following?
Rh incompatibility
Macrosomia (large baby)
Hyperemesis Gravidarum (excessive vomiting)
Polyhydramnios
Gestational Hypertension
Oligohydramnios
Pre-Eclampsia
Group B Strep
Preterm Labor
Gestational Diabetes
ntrauterine Growth Restriction (IUGR)
Placenta Previa
Low Birth Weight
Vena Cava Compression
Other Conditions (not listed above):
EDUCATION
Have you taken, or are you planning on taking, any childbirth education classes?
Where has most of your knowledge about childbirth come from so far? What books, films, family (ie mom, dad, siblings, partner, etc (please include names/relationship)) etc.
What does your support system look like (friends, family, partner, community members)?
PREVIOUS PREGNANCY INFORMATION
How many times have you given birth? (twins, triplets, etc count as 1 birth)
Out of previous pregnancies, how many were carried to term (37+ weeks)?
Out of previous pregnancies, how many were preterm (born 24 - 37 weeks)?
Have you given birth to multiples (twins, triplets, etc)?
Yes
No
How many children do you have? Please list name(s) and age(s):
What types of births have you experienced?
How long did your previous labor(s) last?
Have you had any pregnancy-related health conditions in PAST pregnancies? (Please list)
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HEALTH HISTORY
How is your general health:
Any allergies:
Diet? Vegan/Vegetarian/Other:
Routine OTC meds or vitamins:
Do you use any of the following:
Marijuana
Cocaine/Crack
Methamphetamine or crystal meth
Phencyclidine or PCP
Nicotine/Tobacco
Caffeine
Alcohol
Prescription drugs
Other
If you marked yes to any of these, how often do you use it?
For prescription drugs: If yes, what drug(s)?
What type of exercise do you do? frequency?
Any current health conditions?
Trauma - physical or emotional? Or history of trauma?
Any history of mental health issues or concerns? Any family history?
Please share any additional physical or emotional health details relevant to your pregnancy, labor, or delivery:
ABOUT YOUR BIRTH: MOM
Do you have a birth plan/vision?
Yes
No
Undecided
Preferred birth setting?
How can your doula help?
In what ways can I best support you? Any labor and or delivery needs?
Additional questions or concerns?
ABOUT YOUR BIRTH: PARTNER
What is your vision for this birth?
In what ways can I best support you? Any labor and or delivery needs?
Additional questions or concerns?
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BIRTH EXPECTATIONS & RELEASE
Do you have any religious or cultural beliefs or preferences?
Any fears or concerns related to this pregnancy or birth(physical/emotional)?
Yes
No
If yes, please explain
What type of comfort measures do you think you would like to use during labor?
Distractions
Breathing Patterns
Massage
Birth Ball
Walking, Dancing, Swaying
Water (tub/Shower)
Hot/Cold Therapy
Visualization/Imagery
Focal Points
Aromatherapy
Music
Other Technique(s):
Are you planning to breastfeed your baby?
Yes
No
How do you pay for prenatal care (for your medical provider/ hospital)?
Insurance
Self-pay
If you checked yes to insurance, what type of insurance do you have?
Any other comments or questions:
RELEASE: I, the undersigned, agree that the above information is true to the best of my knowledge. I realize that Ashari Allen may not provide a medical diagnosis, or treatment of any physical or mental ailments, or recommend discontinuance of medically prescribed treatments. I understand that as a doula Ashari Allen offers emotional, physical, and informational support. I give my permission to receive emotional, physical, and informational support from my doula, Ashari Allen.
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Doula Name
Doula Signature
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