Pregnant person full name & preferred pronouns .
*
Pregnant person date of birth.
MM
DD
YYYY
Estimated due date.
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Email
Partner/support person full name (if applicable) & preferred pronouns .
Partner/support person phone
(###)
###
####
Any other support person.
Care provider & insurance provider (if applicable).
Birthing location.
Have you taken a prenatal or childbirth education class if so share date and location and if you haven’t yet would like to please say "I’d love to learn more".
Do you have allergies or food preferences?
What number pregnancy is this for you?
Please note any topics you would like to discuss .
What is your birth vision?
What’s your hope for having doula support? what kind of assistance would you say would be most useful?
Who would you like present during labor?
Would you enjoy any non medical choices while laboring?
Music, food, aromatherapy, showering, jacuzzi, rocking chair, candles, popsicles, fluids, scents?
Do you have any religious or spiritual practices that you would like to incorporate during or after birth?
Feeding & care
(What’s your method of feeding, any concerns, any experience?
What postpartum needs are you interested in?
Any concerns or question you would like to share?
