Doula Client Intake Form

Client/Partner Info

Client Name

DOB

Occupation

Partner

DOB

Partner Occupation

Address

Home/Cell/Work Phone

Partner Home/Cell/Work Phone

Relationship and Family Info

Do you have any other children?

If so, please list names and ages:

Pets?

Any other persons who live in your household?

Health Care Provider Info

Primary Health Care provider (ie Doctor or Midwife)

Phone

Planned place of birth

If hospital birth, have you taken a tour or registered for one?

Baby’s Healthcare provider?

Phone

Have you taken Childbirth education classes? If so, with whom and when?

Any other prenatal classes (breastfeeding, yoga, etc.)?

Any other Healthcare providers you see (acupuncturist, naturopath, etc.)?

Any concerns/feelings/questions about the care you are receiving?

Health History

How is your general health?

Any allergies?

Diet? Vegan/Vegetarian/etc.?

Routine OTC meds or vitamins?

Do you smoke?

Alcohol?

Present Exercise and frequency?

Are you currently receiving care for any health issues?

How is your mental & emotional health?

Trauma – physical or emotional. Anything you would like to discuss as we prepare a safe place for your birth experience?

Anything else about your physical or emotional health that you would like to share as it relates to your pregnancy and labour and delivery?

Family Information

Where does your family live?

Partner – where does your family live?

Plans for family to be involved with birth or postpartum period?

Any relevant information you would like your doula to know or understand about your family or friends involved in the birth process?

Current Pregnancy/Childbearing History

What is your EDD?

Have you been pregnant before?

Have you given birth before?

Have you breastfed before? If so, any special concerns?

Have you ever had postpartum depression? Mother or sister’s?

Circle any that apply for this pregnancy

Indigestion fatigue `tiredness muscle cramps anxiety hemorrhoids nausea vomiting carpal tunnel syndrome incontinence SOB constipation diarrhea lack of sleep swelling

Any medical complications during this pregnancy?

About your birth: Mom

A few descriptive words about your pregnancy so far:

What is your background or experience related to birth?

What is your vision for this birth?

Do you have any fears or concerns about birth?

Do you trust your primary caregiver?

What is your ideal setting for labour?

Do you have any special ideas/requests for your labour? (ie/comfort measures)

What role would you like the Doula to fulfill??

Any special positions or techniques you would like to use? Do you have any emotional or physical aspects of birth preparation that you would like more support with or information on?

Any special things that you do to relax? Do you have a birth plan?

If so, have you reviewed with caregivers? If so, please give a copy to your doula!

Anything else you would like your doula to be aware of to provide the best support possible during your labour and birth? About your birth: Partner

What is your vision for this birth?

Do you have any fears?

What role do you want to take in the birth of your child?

What role do you want the doula to fulfill? What are you thoughts about the pregnancy and upcoming birth?

What do you anticipate your needs to be for the labor and delivery?

What is your background or experiences related to birth?

Any other information you would like to discuss so that I may serve and support you better?

Release  

I,  the  undersigned,  agree  that  the  above  information  if  true  to  the  best  of  my  knowledge.  I  realize  that  Jill  Forse  may  not  provide  a  medical  diagnosis,  treatment  of  any  physical  or  mental  ailments,  or  recommend  discontinuance  of  medically  prescribed  treatments.  I  understand  that  as  a  doula  Jill  Forse  offers  emotional,  physical,  and  informational  support.  I  give  my  permission  to  receive  emotional,  physical,  and  informational  support  from  my  doula,  Jill  Forse.            Date                 Signature  (Client)    Date                 Signature  (Client  Partner)    Date                 Signature  (Doula)