Name
*
First Name
Last Name
Email
*
Address
*
Phone
(###)
###
####
Estimated Due Date
MM
DD
YYYY
Partner support person, pronouns and contact number
*
How/when did you and your partner meet? How would you describe your relationship?
Who is your primary maternity care provider? How/why did you choose them for your birth?
If birthing in a hospital, describe any experiences (in life to date) you or your partner has had within the hospital system.
Birthing Location Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
If you know how were you born, what is your birth story? What are the birth stories of any older siblings?
How did you feel about your menarche (first menstruation)? What is your relationship with your bleeding cycle?
Have you given birth before?
If you have had previous pregnancies, what were the outcomes? (vaginal birth, cesareans, VBAC, multiples, loss etc.) Please include as many or as little details as you'd like.
If applicable, what about those births would you like to be the same or different this time?
Please describe your physical and emotional prenatal and pregnancy experience so far:
Do you have any medical conditions that you feel may affect your pregnancy, birth, or postartum period? If so, please explain:
Have you created a birth a 'plan' or 'map' or established your birth preferences? If not would you like to do this together?
Yes
No
I would like to
If so, are there any special circumstances with this pregnancy that may affect your plan for the birth? Have you shared your birth preferences with your medical provider?
Have you discussed hospital protocols with your care provider if you go past your estimated due date?
Who would you like to be present during your labour?
How does your partner/support person want to be involved in your birth? How would you like them to be involved?
What are your thoughts about pain management during labour? Have you considered it? If yes - what options have you been looking into?
Do you have any persistent concerns and/or fears regarding your birth? Does your parter/support person(s)?
What are you most excited about for this birth?
Is there anything in your personal history that might make it hard for you to cope with the experience of labour and/or lactation? If so, please explain.
Do you have any spiritual or philosophical beliefs or traditions that you would like to be respected and included during this birth?
Have you taken, or do you plan to be involved in a childbirth education class? If so, please list the provider, date, location:
Do you plan on doing any additional classes to prepare (ie. breastfeeding, newborn care, infant CPR, etc.)?
Are there any specific topics you would like to learn more about?
Are you and/or your partner/support person reading any books about pregnancy, labour, postpartum, or breast-feeding?
Where do you carry tension in your body? What do you find helpful for this?
What is your current stress level? How does stress show up in each of you? In what ways do you deal with stress in your life? What helps you to feel calm and grounded?
What do you think will be the greatest challenge for this pregnancy, birth and/or postpartum? What about your partner?
What do you think will be your greatest strength for your pregnancy, birth and postpartum? If applicable, what about your partner/support person? Do you have family and/or friend support close by?
In what ways do you hope a doula's support will be helpful to you in birth and/or postpartum? What types of assistance do you imagine will be most useful for you?
Would you like to create a postpartum plan?
If you like I am happy to walk you and your partner through my postpartum planning document which takes around 1.5-2 hours, usually done in the third trimester. Let me know if this is something you are interested in.
What is your planned method of infant feeding? (breastfeeding, pumping, formula, etc.)
