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Doula Client Questionnaire
Back to Client Portal
Please complete the form below:
Client Information
Name
*
First Name
Last Name
Email Address
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Partner's Name
*
First Name
Last Name
Partner's Phone
*
(###)
###
####
Birth Provider's Name
*
First Name
Last Name
Birth Provider's Phone
*
(###)
###
####
Birth Location
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Please list all persons who will be in attendance at your birth
*
Will you have a birth photographer present?
*
Yes
No
Undecided
If yes, what is your photographer's name?
Have you attended any birth classes?
*
Yes
No
If yes, what classes have you attended?
Are you having a VBAC (vaginal birth after cesarean)?
*
Yes
No
Do you have a birth plan completed?
*
Yes
No
Prenatal
To this point, how has this pregnancy been for you?
*
Please explain in detail to help us better identify areas we can focus our support.
If applicable, please tell us how many children / births you have experienced and describe your birth experience(s).
*
Please identify / explain in detail any concerns, questions, or requested information you may have regarding your pregnancy and upcoming birth.
*
Labor & Birth
Do you have any specific concerns or worries pertaining to your birth or the birth process?
*
Does your birth partner have any specific concerns or worries pertaining to your birth or the birth process?
*
What role do you envision your doula playing in your birth?
*
What typically helps you to relax in stressful situations?
*
Also please list anything that personally annoys you such as phrases, actions, or scenarios
What are your feelings on pain relief? What pain relief options are you considering for your birth?
*
Please describe any additional information that you wish to discuss regarding your labor and birth.
*
Postpartum
Do you have a postpartum plan completed?
*
Yes
No
Do you have an infant feeding plan competed?
*
Yes
No
Do you have a sleep plan completed?
*
Yes
No
Do you have an infant care plan completed?
*
Yes
No
What is your infant feeding preference?
*
Are you interested in learning about our postpartum services?
*
Yes
No
Undecided
Have you ever or do you now suffer from depressions, anxiety, or related conditions?
*
Yes
No
If yes, please describe:
Thank you!
