Welcome Baby KC Labor Doula Intake

Welcome Baby KC Labor Doula Services

Nicole Elliott Bays
To individualize your care for the best experience possible, please take a moment to fill out this Needs Assessment .

I will use this Needs Assessment as a tool to get to know you better.
Full Name:*

First NameLast Name
Email
example@example.com
Your Date of Birth*

MonthDayYear
Date
Cell Phone #

Area CodePhone Number
Occupation
Baby's Date of birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Partner/Spouse's Name
Partner/Spouse's Cell #

Area CodePhone Number
Provider Name
Planned Place of Birth
Baby's Name (if known)
Baby's Sex (if known)
Planned Method of Feeding

BottleBreastMix of Both
Will Baby Be Circumcised?

YesNoUnsureWould like more information
Have you ever been treated for infertility? If so, please describe the treatments orprocedures and when they occurred.
Please list any Medication or Food allergies or illnesses (chronic or otherwise) of which I should be aware. (For you and your partner)
Explain in detail any complications with this pregnancy and any restrictions you have been placed on by your caregiver, including listing any medications you are currently taking.
List any problems or former injuries in your hips, back, neck, or knees that Ishould be made aware of.
Would you like me to take photos of your birth?

YesNoUnsure, might decide in the moment
Please describe your previous birth experiences, if applicable.
Preparations for Birth
Have you taken any childbirth preparation classes? If so, list below.
Please let me know if you're interested in private classes taught by me.
Please list any other classes that you have taken (newborn care, breastfeeding, etc.)
Who will be present for your labor? Who will be present for the birth?
Have you prepared a birth plan? Do you need my assistance with this?

I have one ready!I have not and am not planning to.I have not and I do need assistance with it.Other
Please upload your completed birth plan (if applicable)

Browse Files

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Please rank the following as to what best suits your learning style with 5 being "most like me" and 1 being "least like me".

Visual: I learn by seeing

	1	2	3	4	5

1 is Least, 5 is Most like me

Auditory: I learn by hearing

	1	2	3	4	5

1 is Least, 5 is Most like me

Kinesthetic: I learn by doing

	1	2	3	4	5

1 is Least, 5 is Most like me

Would you describe yourself as an introvert or an extrovert? To answer this question, think about what you do at the end of a long, hard day. Do you need to be by yourself to recharge or do you seek the company of others to recharge?

IntrovertExtrovertMix of BothOther
In nervous or painful situations, how does your body typically react?
In what areas of your body do you feel the most stress?
Emotional Needs Assessment
Client
Partner/Spouse
Client
Partner/Spouse
Client
Partner/Spouse
Contact with your Doula
How often would you prefer to meet prenatally?
Do you wish for me to attend any prenatal appointments or childbirth classes?
Please indicate how I can best assist you and your partner. Include any requests foreducational information (books, videos, internet resources), referrals, or additionalpostpartum care.
DateTime
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Welcome Baby KC Labor Doula Services

Preparations for Birth

Emotional Needs Assessment

Contact with your Doula