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 a birth center birth? * Where do you plan to give birth? * Why did you choose this care provider and birth location? 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 I sometimes diffuse essential oils during birth. Any oils that you love or strongly dislike? Have you ever been diagnosed with depression, anxiety, bipolar, other? * What triggers depression/anxiety in your life? * Have you or anyone else in your family experienced postpartum depression? * Do you have any special concerns or questions you'd like to discuss with me? * How do you want your baby to feel during and after birth? * Natural childbirth is...(fill in the blank) * Natural childbirth is...(fill in the blank) * When I have a natural birth I... * In natural childbirth I... * Why is it important for you to have a natural birth? * What do you see as your partner's role in birth? * Do you plan to receive pain medication during labor? * How do you want to feel during and after birth? * Are there any aspects from your spiritual life you would like included throughout your birth? * What needs to happen in order for you to feel that your work with me was successful? * What would a bad experience feel like to you during birth? * What actions are you currently taking to have the birth experience you want? * Have you taken any childbirth class? If so, which? * What else, if any, reading or preparation are you doing for this birth? * Are there any referrals you would like for me at this time? * Is there anything I should know about your partner? (This is for my eyes only, so feel free to be candid) * Have you ever considered placenta encapsulation to help balance your hormones improve mood, and speed healing after birth? * How do you get exercise, and how often do you move your body? In previous pregnancies, or in this pregnancy, have you experienced musculoskeletal pain (foot, hip, back, pubic, pelvic floor, etc)? Please describe: What is your vision for this birth? Were IUI or IVF involved in getting pregnant? Text 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? Anything I need to know about parking at your home? Name of any other support person who will be at your birth: How would you like me to refer to your baby? * Do you have any religious or philosophical beliefs or practices of which you would like me to be aware? Do you feel you have a community for support in the immediate area? What are you most looking forward to about being a parent? * What fears do you have about early parenthood? * Do you know about the benefits of postpartum doula care? * Is this a planned VBAC (Vaginal Birth After Cesarean)? * How many children do you have? (Specify if by adoption) * Can you tell me about your previous birth(s) What did you love? What did you dislike? What do you want to do differently this time? * Sometimes past sexual trauma impacts the process and experience of birth. With awareness, your care team and I can take measures to help you feel safe throughout your pregnancy and birth. Would you like to talk to me about any past sexual trauma? * Did you experience a serious accident or injury as a child or adult? ( Car accident, fall, sports injury etc.)? * How do you respond to discomfort (headaches/flu/cold/aches) when you are not pregnant? Please explain your emotional response as well as what you normally do to physically relieve the discomfort? * Have you ever been diagnosed with (genital herpes, gestational diabetes, group B strep (GBS), HIV, HPV, Lyme Disease, UTI another STD)? * Do you have any medical conditions that you feel may affect your pregnancy, birth or postpartum? * Tell me about any birth experiences that have strongly impacted you: * Why did you decide to hire me? 🙂 Submit wpx_DoulaQuestionnaire12.12.2020
