Mother's Name * First Name Last Name Email Address * Phone * (###) ### #### Partner's Name Partner's Phone (###) ### #### Partner's Email Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact (Name/Relationship/Phone Number) Estimated Due Date * MM DD YYYY Care Provider Birthing Location Address Address 1 Address 2 City State/Province Zip/Postal Code Country Have you taken a tour of your birthing place? Yes No I'm planning too Allergies? (Food/Medication) Please list any medical conditions or special circumstances that may impact pregnancy or birth Any medical conditions developed during pregnancy None Gestational Diabetes Group B Strep Insomnia Anxiety Depression Hyperemesis Gravidarum (severe morning sickness) Anemia Heartburn Headaches Back Injury/Pain Preeclampsia Any other health conditions or special circumstances that could put you, myself, or others at risk How much, and how well are you sleeping during this pregnancy? What number pregnancy is this for you? Number of previous births (If applicable) Please describe your physical and emotional pregnancy experience so far Have you or are you planning to take a childbirth education class? Please list date and location. Here are some topics that we will be discussing Early labor signs and signals Stages of labor Timing and contractions Comfort strategies/pain management Breathing Techniques Positions for Labor Induction General triage procedures Common medical procedures in labor Medical interventions in labor Positions for pushing Cesarean Delivery Post-birth procedures Newborn procedures Postpartum healing Postpartum support planning Breastfeeding Nutrition Other Are you or your partner reading any books on pregnancy/childbirth/postpartum or breastfeeding. Please list below. Do you have a postpartum support plan? This is good to start thinking about! What is your birth vision? If things go perfectly according to this vision, describe what this looks and feels like for you. This is a big question! Take your time and please know that this doesn't have to be fully figured out and it may evolve as you move further along in your pregnancy. We will talk further about this during the prenatal appointment together. =) Have you made a birth plan? If not, no worries! We can go over this together. Have you shared your birth plan/preferences with your medical provider? No? No problem! We will discuss this in our prenatal appointment. =) During early labor, when does your medical provider want you to call them? Don't know? Totally fine! We will talk more about this in our prenatal. =) Have you discussed protocols with your care provider if you go past your estimated due date? Again, no worries! We will work on a good plan. =) Please describe any activities you have been doing to physically/emotionally to prepare for your birth. (ex. meditation, exercise, etc.) What do you think will be your greatest challenge for this pregnancy/birth/postpartum experience? Do you have any persistent concerns/fears regarding your birth? What will be your greatest strength for your pregnancy/birth/postpartum experience? In previously challenging or emotionally intense situations (illness, injury, surgery, etc.) what have you found comforting? This is important for me to know, but a tough one to answer! We can talk through this at our prenatal appointment. Please check any pain management or relaxation techniques that you would NOT like to use. Check those you DO NOT have interest in Aromatherapy Meditation Directed breathing Massage Acupressure points Visualization Rebozo Heating pad/hot packs Cold packs Music therapy Affirmation Lighting Hydrotherapy (water) Please list any other techniques you would like to try: General Labor/Birth Preferences Mom chooses birth positions Pictures Video (if allowed by medical staff/facility) Perineal Massage Mineral oil and warm compress Prefer to tear over episiotomy Cord cut by Partner Delay cord cutting Mom or partner assist in catching the baby with HCP help Partner announces the sex of baby Baby placed on mom’s chest immediately Delay bath Delay newborn procedures Save Placenta for Encapsulation Other If a hospital birth, here's a list to start thinking about with immediate postpartum Breastfeed only Bottle feed okay Pacifier Eye ointment Vitamin K shot Glucose test Hepatitis B vaccine Circumcision (with anesthesia) In what ways do you hope a doula's support will be helpful for you? Please share anything else you would like me to know about you or any topics you would like to discuss that will help me provide great support for your labor. Thank you for providing your information!
