Pregnant Person's Full Name
*
First Name
Last Name
Pregnant Person's Date of Birth*
MM
DD
YYYY
Partner/Support Person Full Name (if applicable)
First Name
Last Name
Other Support Person (if applicable)
First Name
Last Name
Estimated Due Date
*
MM
DD
YYYY
Care Provider
*
Have you toured the birthing location?
Have you taken a prenatal education class?
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Phone #
*
(###)
###
####
Partner/Support Person's Phone
(###)
###
####
Pregnant Person's Email
*
Partner/Support Person's Email
How much do you usually sleep at night? Do you have an opportunity to rest or nap each day?
What has your prenatal experience been? Emotionally? Physically?
Do you have any allergies (Food, medication, etc) or food preferences?
Medical conditions pertinent to labor and childbirth
Have you ever had any procedures done that might affect your birth experience?
What number pregnancy is this for you?
For Birth Clients: Are you taking childbirth education? If so, please share the date and location.
What would you like to learn in a childbirth class or from our sessions?
Are you and/or your partner/support person reading any books about labor, postpartum time or breastfeeding?
Please note any topics you want to discuss further
What is your birth vision? If things go perfectly, what does that look like for you?
Have you shared your birth preferences with your care provider?
When does your care provider want you to call them/arrive at the birthing location (in case of a home birth, when does your midwife want to join you)?
Have you discussed protocols if you go past your due date?
In what ways are you preparing for this labor, birth & postpartum?
What do you anticipate will be your greatest challenge while in labor?
What do you anticipate will be your greatest source of strength while in labor?
In previous painful situations (i.e. sickness, headache), what methods have you used to comfort yourself?
For Birth Clients: In what ways do you hope a doula's support will be helpful to you? What types of assistance do you imagine will be most useful for you?
For Birth Clients: How does your partner/support person want to be involved in your birth? i.e. Hands on, share support with doula, or let the doula take the lead.
Who would you like to be present during your labor?
Do you want any of the following non-medical choices during labor?
Do you want any of the following medical choices for Early Labor?
Do you want any of the following to occur for the birth?
If your HCP suggest that you have an induction/Augmentation, do you want any of the follow?
If you have a scheduled Cesarean Section or your HCP states that you need one, do you want?
Do you have any special choices?
Do you have any spiritual or religious practices that you would like to incorporate into the birth process or directly after the birth? If so, do you need my assistance with any of this?
What method of feeding your baby are you planning to use?
Do you have any experience with nursing? Tell me about it.
Do you have any concerns about your ability to feed your baby?
Do you have any issues/fears/concerns about newborn care?
Do you want the HCP/staff to:
Do you want...
Do you have any fears or concerns about the postpartum time?
What kind of support will you have? Food/errands/household?
Do you have a pediatrician? If so, who?
Baby's Name (if you want to share)
Do you want any additional information on the following:
Any additional concerns or information needed or want to share?
