Doula Intake Form

Mahogany Maternity

New Client Intake Form
Congratulations on your pregnancy! Thank you for taking the time to fill out this form so I can get to know you better and have an idea of how I can best support you during your pregnancy, birth and postpartum!
Your Name *

First Name Last Name
Your Partner's Name

First Name Last Name
Doctor/ Midwife's / Practice name *

First Name Last Name
Hospital for Delivery *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail
Home Phone *

Area Code Phone Number
Cellphone

Area Code Phone Number
About your baby
Estimated Due Date *

Month Day Year
Baby's Gender

Boy Girl Unknown
Baby's name (if known)
Planned Method of Feeding

Breastfeeding Formula Feeding Both Not sure but would like more information
About your health
Please state your general health
Do you have any allergies I should be aware of?
Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you, and any medications you are currently taking. *
Preperation for Birth
Have you given birth before? *

No Yes,Vaginally only Yes, Cesarean only Yes,Vaginally and Cesarean
Have you taken or are you planning on taking any childbirth education classes? If so, what are they and where are you attending them?
Please list any other classes you have taken or plan on attending.
Who do you plan to have assist you with your labor? *

Partner Doula Mother/ Mother-in-Law Sister Friend
Who do you want present for the delivery? *
Do you have a birth vision planned?

Yes, It is a final copy Yes, but it is a draft and would like some help No, I would like some help writing one. No, I have no interest in one.
How do you feel about interventions in labor/delivery?
What type of pain management are you looking to have? *

Comfort Measures IV Medication Epidural
What type of comfort measures would you like to use in labor?

Distractions Breathing Patterns Massage Birth Ball Walking, Dancing, Swaying Water (tub/Shower) Hot/Cold Therapy Visualization/Imagery Focal Points Aromatherapy Music
What is your vision for this birth? *
What are your expectations of me as your doula? *
Any other questions or concerns?
Should be Empty:

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Mahogany Maternity