Birth Doula QuestionnaireBirth Doula QuestionnaireIf you are human, leave this field blank. Name: * Spouse or Partner: Address: * Address: Address: Address: CityCity State/ProvinceState/Province Zip/PostalZip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Isle of Man Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia ZimbabweCountry 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 No 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?