Birth Doula Client Questionnaire

Baby's name and/or gender:

Estimated Due Date: *

Mother's Name: *

Any other legal names: *

Any other name that you do not use but might be on a driver's license or other legal documents. This is for use in case of emergency.

Partner's name:

Whoever your main support person in your labor will be. Mother, father, friend, etc.

Home Address: *

This should be the address that you want Abbey to support you in prenatal visits, labor, birth, or postpartum visits.

Mother's Age:

Contact e-mail address: *

This should be the best address to send invoices, receipts, or other information during your pregnancy, labor, and postpartum period.

Would you like to be added to Voices of Eve: Birth Ministries' newsletter?

Yes
No
I want more information before I sign up

Mother's cell phone number: *

This is the primary number that Abbey will be in communication with you for your pregnancy, labor, and postpartum period.

Partner's cell phone number:

This should be the number of whoever is your primary support person during pregnancy, labor, birth, and postpartum. For instance a spouse, relative, or friend.

Who do you want present in your labor space during some or all of your labor?

Who do you want present in your birthing space during some or all of the delivery of your baby?

Planned care provider for your labor and birth: *

Planned place of birth: *

What number pregnancy is this for you?

Please include any miscarriages or stillbirths.

What number live birth will this be for you?

This is the number of living children you have delivered.

Were your previous babies born before or after their estimated due dates?

My delivery is planned as: *

If you selected other: *

Any history of psychological disorders:

History of Sexual Abuse or Trauma:

History of Substance Abuse:

This allows me to be aware of any caution surrounding medical pain management that you might want.

Please list any medical needs, conditions, or allergies:

Any experiences that may effect your labor or birth?

include any negative or positive experiences in hospitals or trauma.

Any dietary restrictions:

List any religious/cultural/personal preferences relating to your birth:

This is a good place to note anything you desire to be a part of your birth that is not traditional or commonplace.

What do you most desire for my Abbey's role as your doula? *

What do you most desire for your partner or anyone else's role in the labor or birth space?

In a few words describe your relationship with your care provider:

Medical interventions during labor or birth that I AM comfortable with:

Please select all that apply

If you selected other:

Medical interventions during labor or birth that I am NOT comfortable with:

Please select all that apply

If you selected other:

Medical interventions during labor or birth that I want more information about:

Please select all that apply

If you selected other:

What might make me want to choose induction for my birth:

select all that apply.

If you selected other:

At home labor stimulation/augmentation techniques I am open to try:

Please select all that apply

If you selected other:

At home labor stimulation/augmentation techniques I want more information about:

Please select all that apply

If you selected other:

At home labor stimulation/augmentation techniques I am not comfortable with:

Please select all that apply

If you selected other:

Coping Techniques I am open to try during labor:

Please select all that apply

If you selected other:

Coping Techniques I am NOT open to try during labor:

Please select all that apply

If you selected other:

Coping Techniques of coping during labor that I want to learn more about:

Please select all that apply

If you selected other:

Other elements I want in my labor or birth

What I AM comfortable with during the pushing phase of my birth:

Please select all that apply

If you selected other:

What I am NOT comfortable with during the pushing phase of my birth:

Please select all that apply

If you selected other:

What I want to learn more about during the pushing phase of my birth:

Please select all that apply

If you selected other:

What I am comfortable with after my baby is born:

If you chose other:

What I am NOT comfortable with after my baby is born:

If you chose other:

What I want more information about for after my baby is born:

If you chose other:

How do you feel about your birth plan?

How does your partner feel about your birth plan?

Thank you for taking the time to fill out this questionnaire! All the information within will help Abbey serve you better as your doula. If you have any questions or concerns please add them below.