Birthing Persons Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Can I leave a message at this number?
Can I text you at this number?
Partner / Support Person's Name
First Name
Last Name
Partner / Support Person's Phone
(###)
###
####
Partner / Support Person's Email
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
(###)
###
####
Who is your health care provider?
Estimated Due Date
MM
DD
YYYY
Where is your preferred birthing location
Home
Clinic
Hospital
Address (If you want care to start at home)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Dietary Restrictions
Other food restrictions
Allergies?
Any Medical Conditions that could impact birth:
Any medical conditions developed during pregnancy?
What number pregnancy is this for you?
How many previous births have you had?
If you feel comfortable, can you share about your fertility experience?
Tell me about your previous birth(s) and your experience.
List locations, providers, and personal experiences and how you felt.
List your cute kids and their ages
Did you or do you play a lot of sports? If so, what sports did you play?
Do you have a history of:
During this pregnancy have you experienced:
What prenatal education books have you read?
Describe what your ideal birth situation looks like:
Do you have any persistent fears or concerns?
Check any labour preferences you would like to talk more about:
In what ways do you hope your Doula's support will be helpful to you?
How does your partner/support person want to be involved in the birth? (Hands on, share support with doula, let the doula take the lead)
Is there anything else you would like to let me know?
Has your doctor ever said that you have a heart condition OR high blood pressure?
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?
Are you currently taking prescribed medications for a chronic medical condition?
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.
Has your doctor ever said that you should only do medically supervised physical activity?
Please explain any YES
