Name * First Name Last Name Your Mobile Phone Number * Country (###) ### #### Your Email * Partner's Name First Name Last Name Partner's Phone Number (###) ### #### Your Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Doctor's / Midwife's name * First Name Last Name Address of Hospital / Birth Centre Address 1 Address 2 City State/Province Zip/Postal Code Country Estimated Due Date * MM DD YYYY Baby's Gender Girl Boy Unknown Baby's Name (if known) Planned Method of Feeding Breastmilk Formula Milk Both Not sure but would like more info Please state your general health Do you have any chronic conditions I should be aware of? Do you have any allergies I should be aware of? Medications, Food, Essential Oils, etc.... Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you and any medications you are currently taking. * Have you given birth before? * No Yes, Vaginally Yes, Cesarean Yes, Vaginally and Cesarean Have you taken or are you planning on taking any childbirth education classes? If so, what are they and where are you attending them? Please list any other classes you have taken or plan on attending. Eg. Breastfeeding, Infant Care, Infant CPR, Sibling classes etc... Who do you plan to have assist you with your labor? * Partner Doula Mother/ Mother-in-law Sister Friend Other Who do you want present for the delivery? * Do you have a birth plan? Yes, it is a final copy I have a rough idea what I'd like / not like I haven't thought much about this How do you feel about interventions in labour/delivery? What type of pain management are you looking to have? Non-medical comfort measures IV Medication Epidural What type of comfort measures would you like to use in labour? Distractions Breathing Patterns Massage Birth Ball Walking, Dancing, Swaying Water (tub/shower) Hot/Cold Therapy Visualization / Imagery Focal Points Aromatherapy Music What is your vision for this birth? * Your top 3 most important things What are your expectations of me as your doula? * Eg. When would you like me to arrive, what would you like me to do, How would you like me to help you prepare etc.... What is your favourite way to relax? What hobbies do you enjoy? Any other questions or concerns? Thank you for taking the time to fill out the form. I will be in touch shortly to discuss our next steps. New Client Intake Form
