Doula Intake Form Pregnant Person's Name * First Name Last Name Pregnant Person's Email Address * Pregnant Person's phone (###) ### #### Partner/Support Persons Name Partner/Support Person's Contact Information Emergency Contact Please list their name, relationship to you and phone number Estimated Due Date MM DD YYYY Care Provider Have you decided on your birthing location? Birthing Location Address Address 1 Address 2 City State/Province Zip/Postal Code Country Have you taken a tour of your birthing place? yes no I plan to Any allergies that I should know about? Food, medication, etc. Please list any medical conditions prior to conception that could lead to special medical conditions during pregnancy or birth. Any Medical Conditions Developed During Pregnancy: None Anxiety Depression Headaches Heartburn Back Injury/Pain/ Sciatica Anemia Gestational Diabetes Group B Strep Severe Insomnia Carpel Tunnel Hyperemesis Gravidarum (severe morning sickness) Preeclampsia Pica Other: How much, and how well are you sleeping during this pregnancy? What number pregnancy is this for you? Number of previous births: Please list the number of living children and their ages: Please describe your physical and emotional prenatal and pregnancy experience so far: Have you taken a childbirth education class? Please list date and location. Please check any topics you would like to discuss further: Natural comfort strategies/pain management Breathing Techniques Early labor signs and signals Stages of labor Timing and contractions Positions for Labor Unmediated/Medicated Labor and Birth Unmediated/Medicated Inductions General triage procedures Common medical procedures in labor Pain medications/medical interventions in labor Positions for birthing Assisted vaginal delivery Cesarean Delivery Post-birth procedures Newborn procedures Postpartum healing Postpartum support planning Birth Preferences Feeding and breast feeding Newborn care Postpartum mood disorders Other: Are you and/or your partner/support person reading and books on pregnancy/childbirth/postpartum or breastfeeding. Please list below. Do you have a postpartum support plan? Postpartum Support Plan Team: Family Friends Postpartum Doula Partner Lactation Consultant Please check any postpartum topics you would like to discuss further: Care of perineum Postnatal expectations C-Section recovery Breastfeeding Breast pumps Postpartum Depression Infant Massage Baby wearing Car seat installation and use Circumcision vs. Intact Diet What is your birth vision? If things go perfectly according to this vision, describe what this looks and feels like for you. Have you made a birth plan? (If not, we can do this together) Have you shared your birth plan/preferences with your medical provider? During early labor, when does your medical provider want you to call them? Have you discussed protocols with your care provider if you go past your estimated due date? Please describe any activities you have been doing to physically/emotionally prepare for your birth. (ex. meditation, exercise, etc.) Have you packed a birth bag? (If no, we can do this together.) What do you think will be your greatest challenge for this pregnancy/birth/postpartum experience? Do you have any persistent concerns/fears regarding your birth? What do you think will be your greatest strength for your pregnancy/birth/postpartum experience? In previously uncomfortable or emotionally intense situations (illness, injury, surgery) what have you found comforting? Please check any pain management or relaxation techniques that you would like to use. Massage Acupressure points Aromatherapy Directed breathing Visualization Heating pad/hot packs Cold towel/ ice packs Music therapy Herbal Support Reiki TENS Birth Comfort Please list any other techniques you would like to try: Early Labor Preferences: Continuous Fetal Monitoring Intermittent Fetal Monitoring No IV or Heparin Lock IV Vaginal checks limited to as few as possible Vaginal checks done per HCP/Staff Protocol Spontaneous rupture of membrane Medications offered (i.e. epidural) Medications not offered Epidural/narcotics Other: Non-medical preferences Labor at home Labor in hospital Wear own gown Fluids Ice/Popsicles Food Aromatherapy Music Walking Shower/Bath dim lighting Robe Affirmation cards Other: General Labor/Birth Preferences Mom chooses birth positions HCP chooses birth positions Pictures Video Perineal Massage Cord cut by Partner Cord cut by Care Provider Delay cord cutting Baby caught by partner with HCP help Announce the sex of baby Baby place on mom’s chest immediately Baby cleaned before given to mom Delay newborn procedures for one hour Placenta delivered without Pitocin Other: If a hospital birth, please check your immediate postpartum preferences: Bottle feed Give Pacifier Waive eye ointment Waive Vitamin K shot Waive PKU test Waive Glucose test Waive Hepatitis B vaccine Circumcision (with anesthesia) 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? 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. Please share anything else you would like me to know about you or any topics you would like to discuss. Photographic Release If you checked that you would like photography to document your labor and birth, and the situation allows it, I am happy to take pictures, and with your consent, share them on my website and social media platforms. Please let me know your preferences below, or if you would like to discuss further. Yes, I consent! You may use (non-explicit) pictures of me and my baby with my permission. No, thank you. I would like to keep pictures of our birth private. I'm not sure. Let's chat more about this. Thank you!