Pregnant Person Full Name
* Pregnant Person Full Name
Pregnant Person Date of Birth
* Pregnant Person Date of Birth
Partner/Support Person Full Name (if applicable)
Other Support Person
Estimated Due Date
Your home address.
* Phone #1
Partner/Support Person Phone
Partner/Support Person Phone
Partner/Support Person 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?
Have you ever had any procedures done that might affect your birth experience?
What number pregnancy is this for you?
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?
Do you plan to take any other classes to prepare (ie. breastfeeding, newborn care, infant CPR, etc.)?
Labor and Birth Preferences
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 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 and birth?
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?
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.
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 breast/chest feeding? 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?
If a hospital birth, do you want to room in with your baby or do you want the baby to go to the nursery with partner/family?
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)
Any additional concerns or information needed or want to share?
Ever so often I like to update my website and other printed materials. If you would be willing to allow me to use your photographs, with your name (if desired) taken of your birth (non-explicit photos only), please let me know.
Yes, of course! Feel free to use pictures from my birth (non-explicit only) and/or the postpartum period.
No problem, but only from the postpartum period. No birth pictures please.
Yes, but please let me know which ones before posting
I'm flattered, but I think I'd prefer not to have my pictures online.