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 Lopez Lauren Letterman Melissa Sahhar George Nicole Elliott-Bays

My Full Name *

First Name Last Name

Birth Date

Month Day Year

Baby's Guess Date *

Month Day Year

Preferred Phone # *

Area Code Phone Number

E-mail *

Occupation *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Partner's Full Name

First Name Last Name

Partner Occupation

Partner's Cell Phone

Area Code Phone Number

Preferred Method of Contact *

Phone Email

Do you have other children? Names & Ages

Will they attend the birth?

Yes No Unsure at this time. Not Applicable

Name of OB or Midwife

Planned Birth Location

Pediatrician

Name of Baby (If known)

Sex of Baby (if known)

Girl Boy Surprise! Twin Birth (Make note in seperate box)

Will this baby be circumcised?

Yes No Unknown Please provide more information about this procedure.

Planned method of feeding?

Breast Formula Unknown. 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.

Clear

Welcome Baby KC Doula Services Intake Form