Doula Questionnaire - IT'S DESTINY!

Birth Services
Photography Services
About Me
Contact
Blog

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

fill out as descriptive as you can :)

* Indicates required field

Name *

First

Last

Partners Name *

First

Last

[object Object]

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Partner Phone Number *

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

Has provider changed guess date (due date) *

if yes, why? *

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? *

There are lots of ways to help in birth! Look over list and check items that sound most interesting or helpful *

offer suggestions to partner verbal reminders of my birth plan assist me when i need clarity from staff meet us at our home in early labor Meet us at birth location at request suggestions of birth positions/movement create a calm/relaxing birth space use guided meditations hypnosis prompts/ verbal cues massage / counter pressure assistance with breathe use of birth ball / peanut ball aromatherapy / name fav oils below music / list music of choice below use of water / shower/tub cool applications (wet washcloth, mist) heat applications (heat pad) take photos/video record a timeline of my birth to help me remind the day

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) *

I have lots of information & resources on many topics. Which are the following you would like more information on: *

epidural inductions cesarean other drug options cord clamping circumcision routine procedures for baby procedures after birth for mom big babies fetal monitoring failure to progress GBS induction for due date IV fluids breaking waters vitamin K shot waterbirth eating/drinking in labor birth positions other

other topics you want information on: *

describe your learning style? More hands on, visual, charts, demonstrations, read data, watch videos, listen to instructor, etc *

Who will be present at your birth? *

in other births how close to due date did you go into labor? Induction? *

What were the 1st signs labor started? *

how long did labor last? *

Tell me about your pushing phase: *

What was the most empowering about past births? Any ways you want this pregnancy/birth to be different? *

Do you have a history with postpartum depression? Did you take steps to seek out help? *

Do you have any techniques for managing discomfort? *

Do you feel comfortable being touched? massage, hand rub, counter pressure, etc *

any other special concerns/requests that I can help with: *

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

feeling wishes are respected *

feeling in control of birth *

feeling clear headed and alert during birth *

partner being actively involved *

seeing birth as a spiritual event *

allowing labor to begin naturally *

avoiding medical interventions *

knowing medical intervention is there if needed *

laboring without medication *

feeling minimal pain *

using learned techniques for relaxation *

being able to be active/move *

spending early labor at home *

protecting modesty/privacy *

allowing labor to unfold on its own *

letting my instincts guide me *

being coached through out labor/birth *

experience sensations of birth *

pushing according to your own urges *

seeing, touching babys head while crowning *

catching baby being born *

skin/skin bonding with baby after birth *

any of the above you want to describe? Or anything else thats highly important in your birth? *

The following is for your partner to answer:

in what ways do you help her relax if she had a stressful day? (relaxing music, massage, something that makes her laugh, etc.) *

What do you do for your partner when shes in pain? (does she like help, to be left alone...cold/hot applications, hug, etc) *

how do you make your partner laugh? *

What do the 2 of you like to reminisce about? What are some happy times in your relationship? ?Are there pictures or stories that would help her focus on during labor? *

Does she like to talk about what the baby will be like? How can you help her imagine how baby might be like, look like , etc to help through birth... think of other things to dream about *

What are some ways to verbally encourage your partner when shes feeling discouraged? Does she respond better when you remind her of her goals? *

Do you understand/know her birth goals and what exactly she needs from you to help her? *

What is your household income? *

Less than $10,000 $10,001 - $25,000 $25,001 - $40,000 $40,001 - $70,000 $70,001 - $100,000 Greater than $100,000 Prefer not to say

Submit

Location:Concordia KS

Photography that documents the real, raw BEAUTY, and BIZARRE parts of motherhood.

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

BOOK Today!

* Indicates required field

Email *

Submit

Birth Services
Photography Services
About Me
Contact
Blog