Doula Client Questionnaire
Name
First Name
Last Name
Birth Partner's Name
First Name
Last Name
Aside from your Birth Partner, Birth Team and Doula, do you anticipate the presence of any additional family members or friends in your birth space? If so, please indicate their names and relationships so I can always be certain that your space remains sacred.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Age
Estimated Due Date
-
Month
-
Day
Year
Date
Who is your Provider?
May I talk to your provider about you?
Where are you planning to give Birth?
Why do you want a Birth Doula?
Have you or will you be taking Child Birth Preparation Classes? If so, which Class and with Whom?
Do you have any special needs during your pregnancy and or birth? If so, what are they?
Do you have any health problems that you anticipate may complicate your birth? If yes, what illnesses?
If this is not your first birth, please describe in detail your previous births.
What do you anticipate will be your emotional needs during birth?
Have you had any periods in your life of mental illness, depression, anxiety disorder or previous Postpartum Depression/Anxiety issues that you wish to share with me?
Describe your relationship with your Mother and Father
Describe to me what you envision your Dream Birth to be.
Do you think labor will hurt? If you answered yes, are you afraid of the pain?
How do you ordinarily deal with pain? How do you see yourself coping with pain during labor?
Do you wish to avoid pain medications?
What are some specific desires you have for this birth? If you have a birth plan, please feel free to add send it separately, please respond with "Refer to Birth Plan".
Do you have any cultural, religious or spiritual needs that you would like to share with me?
Submit
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