PVD Doula Initial Questionnaire

PVDDOULA@GMAIL.COM | 917-273-0745

Hello!

Thank you for choosing us! We are excited to work with you and support you through the incredible event that is pregnancy and birth. We have a few questions that will help us prepare for when we meet next. Thank you for taking the time to respond.

Families begin their pregnancies in many different phases of life, from different backgrounds and with different perspectives on birth. Some people have their births planned out and have high hopes as to exactly how they would like the experience to go and others don’t know their options when it comes to care provider, hospital, interventions, experience etc. to even begin to create a plan. There are also some who would rather not have any kind of plan at all, and are looking mostly to their doula and partner mostly for physical and emotional support. There are no right or wrongs here, just different experiences and preferences. Tell me a little bit about yourself.

Bio Info

Mother's Name

First NameLast Name

Mother's Preferred Pronouns

Mother's Phone

Area CodePhone Number

Mother's Email

Mother's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Partner's Name

First NameLast Name

Partner's Preferred Pronouns

Partner's Phone

Area CodePhone Number

Estimated Due Date

Date

Planned Birthplace

Healthcare Provider

Mother's History

Date of Birth

Date

Have you had children and/or pregnancies in the past?

YesNo

Please list any pregnancy issues or past/current medical issues that may affect pregnancy, birth, or postpartum

Questionnaire

Have you read any pregnancy/birth/baby books? Watched any documentaries? Taken any classes? If so, which ones?

This question is a bit similar to the first, but just in case... If you have specific birth preferences, what are they?

Do you feel that you and your care provider are like minded?

What has been your preferred type of exercise during this pregnancy?

Do you want suggestions for prenatal exercise?

YesNo

Are you interested in learning more about the Rebozo technique or Spinning Babies?

YesNo

Do you have any concerns about nutrition or your eating habits during this pregnancy? If so, please let me know what they are.

Who will be present during your labor and birth?

What are your plans for mobility and positioning for labor and pushing?

Which methods of pain control do you foresee being helpful?

Preferences for pain medication? Episiotomy?

What are your preferences for fetal monitoring? Hydration?

Do you have specific preferences for clothing, music, lighting, focal points?

What type of music gets you motivated?

In case a C-section is necessary, do you have any special requests?

What are your plans for the placenta?

Newborn: delayed cord clamp, eye ointment, vit K, Hep B, breastfeeding, circumcision?

Partner: any fears or concerns? What do you foresee for your role/doula’s role?