Partner's First Name (if applicable):
Partner's Last Name (if applicable):
Full Home Address (street, city, zip)*
Do you or your partner have any allergies?
Pregnancy and Birth Information Baby's Estimated Due date: *
Name of Practice & Contact information: *
Where do you plan to deliver: (include name and address)*
Have you had any pregnancy complications? If so, please explain. *
What would you like us to know about your job, education, hobbies or interests to help us understand you better?
What would you like us to know about your culture, upbringing, race or religion to help us understand your perspective?
What is the most stressful aspect of your life right now?
What are some ways you cope with stressful situations?
Questions for your Partner:
For your partner: What would you like us to know about your job, education, hobbies or interests to help us understand you better?
For your partner: What would you like us to know about your culture, upbringing, race or religion to help us understand your perspective?
What are both of your biggest fears about labor and delivery?
Do either of you have any significant medical issues, phobias or sensitivities that would be helpful for us to know about in order to better help you?
What sounds and smells are comforting to you?
Where do you typically hold tension in your body?
What is your love language?
How would you most like to be supported during labor?
Tell us the story of your dream birth:
Is there anything else about your or your birth plan that you’d like to add?
Which of the following topics would you like to us be sure to cover during our prenatal sessions?
Please list anyone else who will be in the home when the doula is present.*
Is there anything else you'd like our doulas to know about you or your family?
