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High Point Doulas

Client Intake Form
Full Name

First Name Last Name
Spouse/Partner Name

First Name Last Name
Estimated Due Date

Month Day Year
Date Date Picker Icon
Phone Number

Area Code Phone Number
Spouse/Partner

Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Occupation
Spouse/Partner Occupation
Does your occupation affect your pregnancy? (stress, work from home, etc.)
Personality (List yours, then your spouse/partner)
Allergies/Illness/Medications/Vitamins, etc. (including any chronic)
Restrictions from your provider
Religious affiliations? Practices or customs?
PLACE YOU PLAN TO DELIVER
Name of hospital, birth center, home, etc.

Address of birthing location (if you are delivering at a home other than your own please enter that address)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Your care provider/s (doctor, midwife, etc.)
Relationship with your provider
Plans for delivery (ex: physiological birth, VBAC, cesarean, etc.)
What is your BIRTH VISION? (any details welcome)
FAMILY
# of Children (ages)
# of Pets (type)
OB HISTORY
# of Pregnancies
# of Deliveries & Types (cesarean, vaginal, water birth, etc.)
Any complications?
CURRENT PREGNANCY
Baby name & gender (if known/want to share)
Plans for feeding (breastfeeding/formula/bottle/pumping)
Special situation? (Surrogate, IVF, pending adoption, etc.)
Prenatal tests performed & results
Any concerns/history with your spine, pelvis, tailbone that may interfere with your labor and/or birth?
Are you utilizing any of these? Check all that apply.

Yoga Acupuncture Chiropractor Physical Therapy
Have/will you take/make preparations (books, classes, websites) for -- Check all that apply.

Pregnancy Childbirth Breastfeeding Newborn/Infant
What kind of learner are you? Check all that apply.

Hands-on Hearing/Listening Seeing/Demonstration Write it down/Take notes
How much information do you want to know? Choose one.

All of it Some of it Very Little
Birth Plan Options (Click box for YES. If you aren't sure, type in comment below)

Labor at home Food/fluids during labor Delayed cord clamping Type option 4 IV Heparin/Saline Lock Warm pack to perineum during delivery Limited vaginal checks/exams Skin to skin when baby is born Internal monitoring External monitoring Natural tearing - no episiotomy Positioning suggestions Postpone newborn procedures Vitamin K for newborn Vaccinations for newborn Cord blood collection for newborn Eye ointment for newborn Breastfeed immediately (when mom and baby are ready)
Were you not sure about any of the previous birth plan options? These are just many examples. Feel free to comment any that you are not sure about and would like more information.
Who cuts the cord after baby is born?
How do you typically handle stress? Partner?
Do you have any anxieties or fears about labor and delivery? Partner?
Do you have faith in your body and trust that you instinctively know how to give birth?

Yes No I don't know...
What role do you see your provider playing in your birth?
What role do you see your partner playing in your birth?
What role do you see your doula playing in your birth? What are your expectations of her/them?
DELIVERY DAY
List all support person/s & relationship/s (ex: Anne/sister)
Coping strategies you plan to use
Pain medications?
Environmental needs? (diffuser, low lights, etc.)
Feelings on induction?
Please choose a code word for during labor (unique, for example: watermelon, basketball, banana, etc). We will discuss this during our prenatal visit/communication.
Comfort Measures - Choose any that you'd be willing to use/try.

Hot/cold therapy Labor tub (if available) Shower Birth ball & peanut ball Massage Visualization (Read, guided, etc.) Relaxation & breathing patterns Distration Counter pressure Hypnosis Walking & position changes Rocking chair Aromatherapy Yoga Vocalization Focal points Music
CESAREAN BIRTH (Enter in the information even if you are planning on a physiological birth)
Date & Time
Someone to watch/explain the surgery (nurse, doula, etc.)
Nausea medication?

Yes No I'm not sure, I need more information.
Who attends? (partner, doula, etc. Be sure to check with the hospital on their policy for cesarean deliveries & support persons)
Partner's participation (trimming cord after doctor has cut it, staying with baby at all times, making medical decisions, etc.)
POSTPARTUM PLAN
Who will be helping? (partner, mother, etc.)
Would you like lactation resources (if breastfeeding/pumping)?

Yes No I don't know
Previous experience with postpartum depression or baby blues?
Any additional postpartum comments or concerns?
Would you like information on postpartum doulas who may serve your area?

Yes No I don't know
What are your plans for maternity leave? How long are you planning to be home? How about your partner?
How did you hear about us? Who should we thank?
Would you be interested in any pre-approved (by you) pregnancy/labor/birth photos being featured on our social media accounts, website, or articles, etc.? If yes, we will send you a release form to look over.

Yes No I don't know, let's talk it over some more.
Would you be interested in adding a testimony about our services to a few websites (Doulamatch, Stillbirthday, Facebook)? Would you allow us to use your testimony on our website?

Yes No I don't know, let's talk it over some more.
Any additional comments or concerns, please list them here.
Email *
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High Point Doulas