Doula Questionnaire

Name *

First

Last

Partners Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Partner Phone Number *

Baby's Guess Date ("due date") *

Has provider changed guess date (due date) *

Babys gender / name? *

Providers Name *

First

Last

Name of providers practice *

Name of birth location/ city/ state *

Providers Phone Number *

other births, pregnancies, and a little about each *

other childrens name/ages *

any allergies, sensitives, or diet restrictions? If yes, describe *

current exercise type and frequency: *

Currently receiving any care for medical condition (not pregnancy) or contagious disease? *

any specific neck, back, or pelvis issues? *

any major traumas/accidents have you experienced? (falls, car accidents, broken bones, etc) *

any procedures done to your cervix *

previous pregnancy complications/discomforts and treatment sought *

complications, issues, etc from past births *

results from glucose test (if any) *

results of Group B Strep test *

attending any birth class or going to before birth? Or reading any materials, describe: *

Do you plan on writing up a birth plan, do you want help with it? *

Do you plan to breastfeed? Any difficulties in the past? *

Is there anything special you would want more information on birth, breastfeeding, or postpartum? describe *

Do you plan to return to work? when? *

What kind of support do you visualize from me? Hands on, giving tips to partner, fly on wall, etc. *

What are some ways I could best support you during your birth? *

What do you want in your birth? How do you envision your perfect birth? *

other ways you like to relax, feel would be helpful in your birth, music/sound of choice, favorite aromatherapy oils *

How do you feel pregnancy is going so far? Is it what your excepted? Do you feel like your getting enough rest/able to relax? *

Anything stressful in your life at this time? *

What types of self care are you doing for yourself? *

What kind of support system do you have in place? Who is available to help around the house, with other children? Do you have anyone to turn to in times of stress? *

Do you have any life traumas that you feel I should be aware of that might impact your pregnancy, birth, postpartum *

Have you had an open discussion with your provider about your birth wishes/goals? Do you feel you share similar goals? Do you trust your provider to help support your choices? Have you met other providers? Have you toured the birth location? *

Do you have fears surrounding pregnancy/birth? What steps have you taken to address these? *

Are you open to suggestions or holistic therapies? (dietary, chiropractic, herbal, acupuncture..etc) *

Location:Concordia KS

i am inspired by giggles, random acts of randomness, raw beauty, birth, babies, and friendships.

Questions to help uncover how I can best help in your BIRTH

fill out as descriptive as you can :)

On the following rate 1-5, 5 being the most important to have during your birth

The following is for your partner to answer:

Location:Concordia KS

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