Name

First Name

Last Name

Partner's name (if applicable)

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Partner's phone (if applicable)

(###)

###

####

Due Date

Place of birth

Who else will attend the birth?

Are you interested in birth photography?

Yes

If so, what are your preferences?

What have been your biggest highlights during this pregnancy?

What have been your biggest challenges during this pregnancy?

What are your goals for this birth experience?

What are your goals and hopes in adding a doula to your birth team?

Are there specific things you are hoping a doula will provide?

Are you planning on using any specific coping techniques during labor?

What about these techniques inspires you? How can your doula help to support you in these alternatives?

How do you tend to seek comfort, for both emotional and physical challenges?

Who is your doula/doula team?

Atika

Camilla

Who else will be present at the birth? How do you envision them taking part of the experience?

What are you doing to prepare? Are you taking any classes or seeking out specialized care?

One of the roles of a doula is to provide physical support during labor. Do you imagine touch might be an avenue to providing you relief and comfort during your birthing process? And are there particular places you like to be touched? Are there places you’d prefer we avoid?

Do you have any specific fears or concerns?

Have you ever been pregnant?

Have you ever had an abortion, miscarriage, or stillbirth?

Have you ever given birth and relinquished for adoption or surrogacy?

Have you given birth and continued care for the child?

Please describe your past pregnancies/births. What went well? What would you like to do differently this time?

Care Providers (Primary Care Provider, Pediatrician, Massage/Acupuncture/Chiropractor/Therapist):

Describe your relationship with your primary care provider.

General Health History, including allergies:

Any specific issues? (hemorrhoids, accidents, chronic pain, nerve damage, migraines, blood disorders, etc)

Have you ever had a cervical procedure that maybe have caused scarring, such as a LEEP, cryosurgery, D&C, or IUD insertion?

What is your diet like? Any particular challenges or allergies?

What physical activities and exercises to you engage in? How often do you participate?

Mental Health: History?

Concerns?

How are you preparing mentally for birth?

Are there any modalities or activities that you use to provide mental strength?

How do you plan on feeding your infant?

Nursing

Bottle feeding with breast milk

Bottle feeding with formula

Supplementing breast milk with formula

Do you have a history with feeding infants?

Do you have any concerns about feeding?

Do you notice any changes in your breasts (shape, size, nipples, etc)?

Do you have flat or inverted nipples?

Have you had breast surgery or nipple piercings?

What techniques do you employ for dealing with stress? Can you imagine their effectiveness during birth?

Are you planning on taking an infant feeding class? Or do you need resources surrounding this topic?

Other Considerations: Our goal as your doulas is to support you as your strive for your ideal birth. Are there any other considerations we might need to be aware of to help keep you focused and grounded during birth? Some families share with us cultural, spiritual, or religious beliefs and practices, traumas or abuse, and sensitivities or pet peeves. If there is anything that comes to your mind please feel free to share here or discuss with us in person.

How do you visualize your ideal birth experience? How do pregnancy, birth, and postpartum fit into this picture?

For Partner: What are your experiences with birth?

Do you have any specific fear or concerns?

What do you feel like you need more preparation or information about?

How can a doula best support you?

What ways do you envision supporting your partner?

How do you visualize your partner’s ideal birth experience? How do pregnancy, birth, and postpartum fit into this picture?

Birth Intake

Full Circle Baby