Birth Doula Questionnaire

If you are human, leave this field blank.

Name: *

Spouse or Partner:

Address: *

Address:

City

State/Province

Zip/Postal

Country

Phone: *

Cell Phone: *

Email Address: *

Name of Care Provider: *

Where do you plan to give birth? *

Due Date *

Your Pregnancy

How is your pregnancy going?

Are you attending childbirth education classes?

Yes

Where?

Are there any pregnancy complications I should know about?

Are there any other medical or physiological needs I should know about?

Getting to Know You

What kind of work do you do? What does your partner do?

What do you do for fun? How do you spend some typical time away from work?

What are the most stressful aspects of your life at present?

What do you do to counteract this stress? Do you have any relaxation routines?

Who do you turn to for support?

How will these people help you add a new baby to your family?

Your Upcoming Birth

Who do you want to be present?

What expectations do you have of a doula?

What coping techniques do you plan on using during labor and birth?

Imagine your ideal birth. What makes it ideal?

Knowing that birth is sometimes less than ideal, what things in your ideal birth scenario are the most important to each of you?

What are your greatest fears about this birth?

In the event of an unanticipated cesarean birth, what aspects of the birth experience would be the most important to you?

Your Newborn

In ideal circumstances, how would you like to welcome your child?

What is most important to you in the 30 minutes after birth?

Previous Experiences

Have you had any childbearing losses?

Have you had any other life traumas that you think might influence your birth experience?

Have you had a previous birth experience? If so please give a brief overview. When/how did labor begin? What was the best thing about this experience? What elements would you like to do differently this time?