lunamama
Kimberly
Prenatal Classes
Gift Certificates
Local Resources
Birth Doula Intake Form
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Indicates required field
Name
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First
Last
Preferred name
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Partner's Name
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First
Last
[object Object]
Partner's preferred name
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Estimated Due Date
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Care Provider(s):
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Planned Place of Birth
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About You
Your preferred pronouns
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Your age at your estimated due date
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Address (Street AND Mailing if different)
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Line 1
Line 2
City
State
Zip Code
Country
Your partner's preferred pronouns
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Partner's age
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Special directions to your home
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Your mobile
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Partner's mobile
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Partner's work number
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Home line
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Your email
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Partner's email
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Preferred method of communication
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Email
Phone call
Text
Your occupation
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Partner's occupation
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Children's names & ages
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Pet's names
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Others who will be home during your labor/birth
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Who referred you to our services?
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Plan for children and/or pets during labor
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Food allergies or dietary restrictions:
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About Your Care Providers & Birthplace
Primary Care Provider for this pregnancy
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Planned Birthplace
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Care Providers phone/pager number
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Back-up Birthplace
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Have you taken a childbirth preparation class?
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YES
NO
Have you taken a newborn care or breastfeeding class?
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YES
NO
Other classes? (prenatal yoga, infant CPR, parenting classes)
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List all Health Care Practitioners/Supports for this pregnancy (acupuncturist, chiropractor, physio therapist, naturopath, counsellor)
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About Your Pregnancy
Menstrual History
PMS symptoms
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Coping techniques
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Method of birth control before conception
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Childbearing History
Prior pregnancies and births
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Have you experienced pre-natal depression/anxiety?
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Have you breastfed/chestfed before? Any challenges?
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Have you ever experienced postpartum mood disorders?
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History of this pregnancy
Has your estimated due date changed? Reason for change?
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What is your blood type?
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Any symptoms or health conditions that concern you?
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Do you have any health conditions we should be aware of?
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About Your Birth
Your specific wishes for your labor and birth
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Partner's specific wishes for this birth
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What are your expectations of your doula?
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Will there be family/friends involved with your birth and/or postpartum period?
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Would you like photos of your labour and birth?
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Yes
No
I would like more information
Would you like to keep your placenta?
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Yes
No
Uncertain at this point
Submit
Kimberly
Prenatal Classes
Gift Certificates
Local Resources