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Every Birth Lancaster
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Doula Client Intake Form
Mothers First & Last Name
Partners First & Last Name
Mothers Email
Partners Email
Mom's Phone
Partner's Phone
Home Address
Estmate Due Date
Care Provider
Birth Location
Have you taken a tour of your birthing place?
Yes
No
I plan to
Please list any medical conditions prior to conception that would impact pregnancy or birth.
Any Medical Conditions Developed During Pregnancy:
None
Gestational Diabetes
Group B Strep
Severe Insomnia
Anxiety
Depression
Hyperemesis Gravidarum (severe morning sickness)
Anemia
Heartburn
Headaches
Pica
Back Injury/Pain
Preeclampsia
Please list any medical conditions prior to conception that would impact pregnancy or birth.
Please describe your physical and emotional prenatal and pregnancy experience so far:
What number pregnancy is this for you?
Number of previous births:
Please list the number of children, their names and ages
Have you taken a childbirth education class? Please list date and location.
Are you interested in taking Heathers Bradley Method Class?
Yes
No
Would like to discuss
Do you plan to take any additional childbirth/newborn education classes? Please list date and location.
Are you and/or your partner/support person reading any books on pregnancy/childbirth/postpartum or breastfeeding. Please list below.
Please check any topics you would like to discuss further:
Ways labor can begin
Early labor signs and signals
Stages of labor
Timing and contractions
Natural comfort strategies/pain management
Breathing Techniques
Unmedicated/Medicated Labor and Birth
Unmedicated/Medicated Inductions
Positions for Labor
Positions for pushing
Post-birth procedures
Newborn procedures
Newborn care
Postpartum healing
Postpartum support planning
Feeding and breast feeding
Other:
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?
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.)
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.
Massage
Acupressure points
Aromatherapy
Meditation
Directed breathing
Visualization
Heating pad/hot packs
Music therapy
Please list any other techniques you would like to try:
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 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.
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Thank you!
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