Client Intake Please click here to join my resource library. Name First Name Last Name Phone (###) ### #### Partner's Name First Name Last Name Partner's Phone Number (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Name of Care Provider or Group Birthing Location Have you completed a tour? yes no Estimated Due Date MM DD YYYY Please list any test results or conditions that have been placed on you or your pregnancy. Is there anything in your medical history (such as conditions, surgeries, or past pregnancy experiences) that you think would be helpful for me to know as your doula? What number pregnancy is this for you? Number of previous births Have you taken a childbirth class? yes no If yes, which one or with whom? Do you have a birth plan? yes no Do you have a postpartum plan? yes no Names of people you want to be with you at birth: When you are anxious or nervous how does your body respond? (check all that apply) fidgeting rapid heart rate sweating breath holding grinding teeth/clenching jaw hyperventilation nausea/vomitting nail biting other Where does your body manifest tension? (check all that apply) back forehead neck/shoulders jaw chest lower body other What do you use to cope with stress or pain? (check all that apply) distraction sleep activity/exercise music bath/shower massage being around people being alone other Knowing that everything is flexible, what are your preferences for coping with labor? Are there any words or phrases you would prefer I not use? Any words you want me to use? Do you have any religious or cultural beliefs of which you would like me to be mindful? Anything else you would care to share? What are your favorite/ go to snacks and drinks? What is your favorite/ go to meal? Thank you for completing the client intake! This information will help me prepare for our prenatal visits, pack my doula bag with individualized comfort measures, and support you through labor and birth.
