Doula Intake form

Name *

First

Last

Preferred name *

Partner's Name *

First

Last

Partner's preferred name *

Estimated Due Date *

Care Provider(s): *

Planned Place of Birth *

About You

Your preferred pronouns *

Your age at your estimated due date *

Address (Street AND Mailing if different) *

Line 1

Line 2

City

State

Zip Code

Country

Your partner's preferred pronouns *

Partner's age *

Special directions to your home *

Your mobile *

Partner's mobile *

Partner's work number *

Home line *

Preferred method of communication *

Email Phone call Text

Children's names & ages *

Pet's names *

Others who will be home during your labor/birth *

Who referred you to our services? *

Plan for children and/or pets during labor *

Food allergies or dietary restrictions: *

About Your Care Providers & Birthplace

Primary Care Provider for this pregnancy *

Planned Birthplace *

Care Providers phone/pager number *

Back-up Birthplace *

Have you taken a childbirth preparation class? *

YES NO

Have you taken a newborn care or breastfeeding class? *

YES NO

Other classes? (prenatal yoga, infant CPR, parenting classes) *

List all Health Care Practitioners/Supports for this pregnancy (acupuncturist, chiropractor, physio therapist, naturopath, counsellor) *

About Your Pregnancy

Menstrual History

Childbearing History

Prior pregnancies and births *

Have you experienced pre-natal depression/anxiety? *

Have you breastfed/chestfed before? Any challenges? *

Have you ever experienced postpartum mood disorders? *

History of this pregnancy

Has your estimated due date changed? Reason for change? *

What is your blood type? *

Any symptoms or health conditions that concern you? *

Do you have any health conditions we should be aware of? *

About Your Birth

Your specific wishes for your labor and birth *

Partner's specific wishes for this birth *

What are your expectations of your doula? *

Will there be family/friends involved with your birth and/or postpartum period? *

Would you like photos of your labour and birth? *

Yes No I would like more information

Would you like to keep your placenta? *

Yes No Uncertain at this point

Birth Doula Intake Form