Mother's Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Occupation
*
Support Person's Name
First Name
Last Name
Support Person's Phone
(###)
###
####
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Number of Children and Ages
*
What is your plan for children during labor?
*
Please list any additional people who will be attending the birth.
Provider's Name & Type of Practice
Designated Place of Birth & Address
*
Back up hospital if home birth/birth center
Is your provider aware you are using a doula?
*
Yes
No
Estimated Due Date
MM
DD
YYYY
Have you discussed with your provider the possibility of going past 40 weeks? If yes, please provide provider's opinion.
How do you feel about going past 40 weeks?
Are you working with any other care providers?
Chiropractor, Acupuncturist, Naturopath, etc.
Do you have any high risk factors associated with this pregnancy?
Are you taking any medication? Have any known allergies or sensitivities?
Are you experiencing any of the following pregnancy symptoms?
Please check all that apply.
Do you require specific dietary needs?
Vegan, Dairy Free, Gluten Free, etc
Is this your first pregnancy?
*
If no, please state number of pregnancies and outcome of each one.
Example: Two pregnancies
First-miscarriage
Second- vaginal birth
Please describe previous birth experiences
Feel free to include weeks gestation, length of labor, complications, place of birth, medications, emotional/physical response to birth, care providers, support team, and any other details you wish to share. We can also talk more about this during our prenatal visit.
Have you and your partner taken a childbirth education class?
*
Yes
No
We have one scheduled
If yes, what kind of class did you take?
Describe your ideal birth.
Don't worry if you haven't thought through all the details, just share from the heart what you are hoping for. We will go into more details during our visit
Describe your emotions surrounding this pregnancy.
Do you have any worries, fears, or anxieties about this pregnancy?
Do you have any physical or mental health concerns that may impact your pregnancy, birth, or postpartum recovery?
Are there any current life stress or events that you feel may impact your pregnancy, birth, or postpartum recovery?
What are your feelings regarding your body, baby, and partner during this pregnancy?
What are your feelings regarding medical pain relief and interventions during labor and birth?
Do you have any specific cultural, philosophical or spiritual beliefs or traditions that you would like to be honored and respected during this birth?
When you've had a hard day, how do you like to relax or let off steam?
Where in your body do you carry most of your tension?
Neck, Traps, Back, Hips, etc.
Describe your experience with essential oils. Are you wanting to use oils during your birth?
Is there anything else you would like to share at this time?
Social Media Photo Release
I am comfortable with any photos from my birth being shared on social media.
I am comfortable with photos from my birth being shared (excluding nipples and vulva).
I am comfortable with photos from my birth being shared (excluding breast, vulva, and bottom).
I want any photos to be approved before being shared.
I do not want any photos from my birth to be shared.
