Questionnaire Your Name (required) * Estimated Due Date Is your baby a boy, girl or a surprise? Date of Birth Occupation Husband/Partner Name Husband/Partner Name Occupation Your Address Your Email Address (required) * Partner's Email Address * Copy partner on emails? Yes No Home phone Cell phone Partner's cell phone Best way for me to contact you Phone Text Email Religious Affiliation Special Customs Name/Nickname of your baby Does anyone else live in your home? Yes No Name of OB/Midwife Their phone How would you rate your communication with your OB/Midwife? Fair OK Good Great Have you toured and registered at the hospital? Yes No Which & where? Have you taken a breastfeeding class? Yes No Which & where? Do you have any questions about the care you are receiving? Have you taken any other prenatal or newborn classes (massage, yoga, etc.)? Have you ever considered home birth? Have you ever considered using a brain training program such as Gentle Birth or Hypnobabies for birth? Have you ever been diagnosed with: Genital herpes HIV HPV Gestational Diabetes Group B Strep On a regular basis do you prefer: Over the counter medication Natural alternatives How do you respond to everyday pain (headaches/flu/colds etc.) when you are not pregnant? Please explain your emotional response as well as what you normally do to physically relieve the pain. Pre-pregnancy weight Current weight Are you RH-? Yes No Have you ever had a breast reduction? Yes No Have you ever had a breast augmentation? Yes No Have you seen other care providers (i.e. acupuncturist, chiropractor)? Do you want/need additional information about: Pregnancy Nutrition Exercise Breastfeeding Baby Care Postpartum period Share your blog or family website URL if you have one: Do you have faith in your body and trust that you and your baby instinctively know how to give birth? Yes No If no, please explain. What are you and your partner's hopes or expectations for this birth? (Tell me what you're wishing for... What are you and your partner's fears/anxieties? What are you and your partner's wants/desires? Have you ever seen someone or an animal give birth before in real life (not TV or movie)? Yes No If Yes, please explain: What do you know about the birth experience of your mother and your partner's mother? Please describe any other birth experiences that you are aware of that have strongly impacted you: What are you expecting from your doula during birth? What role do you see your partner playing during birth? Do you have any food allergies? Do you have any medical allergies? Do you have a special diet? Please list any supplements, vitamins or medications you currently take: Please check any cervical procedures you have received: Removal of tissue after a miscarriage Iinsertion of an IUD Treatment for abnormal Pap smear or genital warts (i.e.cryosurgery/LEEP procedure) Cervical or uterine biopsy Removal of polyps Abortion How would you describe your personality? Have you ever dealt with vaginismus (pain during sex)? Yes No Did you drink alcohol prior to pregnancy? Yes No Have you ever taken the birth control pill? Yes No If Yes, for how many years? Do you exercise? Yes No Have you ever been diagnosed with: depression anxiety bipolar Other Are you receiving care for any other physical or mental health issues? Yes No Do you or your partner have friends or family involved in the birth that you would like me to be aware of? Have you ever been pregnant before? Yes No Have you given birth before? Yes No Do you plan to breastfeed? Yes No Any concerns about breastfeeding? Have you or your family experienced postpartum depression before? Yes No Have you ever considered placenta encapsulation to help balance hormonal imbalances, mood and healing after baby is born? Yes No Have you experienced any complications with this pregnancy? Are you experiencing any discomforts? Have you ever suffered a serious accident or injury (car, horseback riding, fall) as a child or adult? Do you have any special concerns or questions you would like to discuss during our visit? Why did you decide to hire me? 🙂 If you are human, leave this field blank. Submit wpx_DoulaQuestionnaire12.12.2020
