Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Your date of birth
*
MM
DD
YYYY
Partner's name
*
First Name
Last Name
Partner's phone number
*
(###)
###
####
Partner's relationship to you
*
Estimated due date
*
MM
DD
YYYY
How may weeks pregnant are you today?
*
Place of birth
*
Care provider
*
Child's gender
*
Birth doula package selection
*
Total number of pregnancies, including this one
*
Please list any infertility treatments you have gone through.
Current medication list.
*
Describe your previous birth(s), if applicable.
Describe your level of activity throughout the day. Do you sit at a desk? Do you stand a lot? How often do you participate in recreational activities and of what sort?
*
How often during the week do you exercise? Please also describe what you do to exercise. This could include walking, lifting weights, yoga, barre, etc.
*
What are the main reasons you chose to work with a doula?
*
How would you describe your pregnancy so far?
*
Have you experienced any complications with this pregnancy?
*
Have you been labeled high-risk by your care provider? If so, please briefly describe why?
*
Do you have any pre-existing medical conditions that may affect your pregnancy/birth/postpartum?
*
It is my desire to provide the best possible emotional support for you and your partner. Have you had any life experiences that may impact your pregnancy/birth/postpartum? Share to your comfort and know we can have future conversations on this topic in person, if that would best serve you.
*
What type of birth do you desire to have? What do you envision for it?
*
Are you planning to or currently taking a childbirth or breastfeeding class? If so, which one(s)?
*
Do you plan to breastfeed?
*
If there is anything about you, your partner or pregnancy, upcoming birth or child that you feel would be helpful for me to know, please share that here.
How did you learn about my doula services?
*
