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 Name (if applicable)
Partner/Support Person's Phone
(###)
###
####
Partner/Support Persons Email
Estimated Due Date
MM
DD
YYYY
Care Provider
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?
Pregnant Person Allergies? (Food/Medication)
Please list any medical conditions prior to conception that would impact pregnancy or birth.
Any Medical Conditions Developed During Pregnancy:
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.
Do you plan to take any additional childbirth/newborn education classes? Please list date and location.
Please check any topics you would like to discuss further:
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:
Please check any topics you would like to discuss further:
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 painful or emotionally intense situations (illness, injury, surgery) what have you found comforting?
Please check any pain management or relaxation techniques that you would NOT like to use.
Check those you DO NOT have interest in
Please list any other techniques you would like to try:
Early Labor Preferences:
Other
Non-medical preferences
Other
General Labor/Birth Preferences
Other
If a hospital birth, please check your immediate postpartum preferences:
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?
other
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.
