WBKC Doula Services Intake Form

The information gathered from this form is for my eyes only, and is used as tool so that I may better support you. You may skip any question(s) that you do not wish to answer. We will go over this sheet and the information at our prenatal visits.

My doula is

Stacie LopezLauren LettermanMelissa Sahhar GeorgeNicole Elliott-Bays

My Full Name*

First NameLast Name

Birth Date

MonthDayYear

Baby's Guess Date*

MonthDayYear

Preferred Phone #*

Area CodePhone Number

E-mail*

Occupation*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Partner's Full Name

First NameLast Name

Partner Occupation

Partner's Cell Phone

Area CodePhone Number

Preferred Method of Contact*

PhoneEmail

Do you have other children? Names & Ages

Will they attend the birth?

YesNoUnsure at this time.Not Applicable

Name of OB or Midwife

Planned Birth Location

Pediatrician

Name of Baby (If known)

Sex of Baby (if known)

GirlBoySurprise!Twin Birth (Make note in seperate box)

Will this baby be circumcised?

YesNoUnknownPlease provide more information about this procedure.

Planned method of feeding?

BreastFormulaUnknown. Please provide more information.

Have you taken a Childbirth Class? Which one & Where?

Have you taken any other prenatal or newborn classes?

Have you seen any other care provider during this pregnancy? (ie Acupuncturist, chiropractor, therapist, etc.)

Would you like to share any test results from this pregnancy? ie: Gestational diabetes, group B strep, etc.

Do you have any medical conditions or diseases that may affect my care for you?

Have you ever had a LEEP procedure or any other cervical procedure?

Have you ever been sexually or physically abused?

Do you have any questions or concerns about the care that you are receiving?

Do you have any allergies or special diet considerations?

Is there anything else you want to share about your physical or emotional health related to your pregnancy and birth that will help me better serve you?

Please explain how you typically cope with stressful or uncomfortable situations:

Is there any information about friends or family that may be involved in this birth that you wish for me to be aware of?

What are your hopes and expectations for this birth?

How can your Doula best assist you and your birth partner? Please include any requests for referrals or additional postpartum care.

Welcome Baby KC is collecting this information as it pertains to your case only. They will only share this information with a trusted partner & back-up doula, should it become necessary. Outside of that, they will never divulge your private information to anyone without your express consent.

Please sign in acknowledgement of the above.

Welcome Baby KC Doula Services Intake Form