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BIRTH DOULA INTAKE FORM
Please fill out the following sections as completely as possible.
Thank you for taking the time to fill out this form. Having this information prior to our first prenatal appointment helps us to utilize our time together more effectively and serve you better. If you have any questions, please do not hesitate to ask.
Please note, this information is private and will not be shared with any parties with out your express consent.
CONTACT INFORMATION
*
Indicates required field
Name
*
First
Last
Cellphone Number
*
Email
*
Date of Birth
*
Ocupation
*
Would you like to be added to our mailing list? (To receive our newsletter, special announcements or unique offers - Don't worry. We won't spam you.)
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Yes!
No, thanks.
Address
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Line 1
Line 2
City
State
Zip Code
Country
Preferred Form of Communication
*
Email
Phone call
Text Message
How did you hear about us? If you were referred, please let us know so we can say thank you to them!
*
ADDITIONAL SUPPORT PERSON
(IF YOU HAVE ONE)
Name
*
First
Last
Cellphone Number
*
Relationship
*
Ocupation
*
YOUR PROVIDER AND BIRTH LOCATION
Type of Provider
*
OB
Midwife
Family Doctor
Other
Name
*
Where are you planning to give birth?
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YOUR HEALTH INFORMATION
Estimated Due Date
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What number pregnancy is this for you?
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What number birth is this for you?
*
Have you taken a Childbirth Education Class? Which?
*
What about breastfeeding classes?
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Do you know the sex of the baby?
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Girl
Boy
It's a surprise!
We don't know yet
Please tell me about your previous pregnancies/births.
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How do you plan to feed your baby?
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Breastfeeding
Bottle Feeding
Combination
Undecided
In general, how have you felt throughout the pregnancy? Describe any difficulties/challenges/complaints/perks?
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Who do you plan having present at your birth and what are their roles?
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If you have any concerns or questions about breastfeeding, list them here.
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What type of birth are you planning for?
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Do you have any concerns about your upcoming birth experience? What are they?
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Is there anything I should be aware of, as your doula, in order to provide the best possible care?
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Because of the unique challenges of birth, it is possible that a prior trauma or violent incident can impact your birth experience. By being aware of this I can better serve you, however, please share only what you are comfortable with.
Do you have any other questions, comments or concerns?
*
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Child Birth Education
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