YVR DOULA INTAKE FORM

First name

Last name

Phone

Email

Partners name (if applicable)

Partners Phone # (if applicable)

House Address

Due Date

Care Provider

Planned place of birth

Who else will attend the birth?

Gender of baby

Boy

Girl

Surprise

Group B strep result

Negative

Positive

Not tested yet

Do you have a backup doula? If so, who?

Back up Doulas phone #

Have you attended childbirth classes?

Yes

No

If so, with whom?

How has the pregnancy been so far?

Any food allergies or restrictions?

Do you have any birth ceremonies or special requests?

Would you like any photos or videos taken during the birth?

Yes

No

Would you like to take the placenta home?

Yes

No

Are you working with supporting care providers?

Have you had previous pregnancies or births? If so, what are the child(ren) names and ages? Lengths of births?

Would you feel comfortable with non-medicated comfort measures such as TENS machines, Robozo, hydrotherapy, or sterile water injections?

Yes

No

I need more information

Would you feel comfortable with the use of nitrous oxide?

Yes

No

I need more information

Would you feel comfortable with the use of narcotics such as morphine/ fentanyl?

Yes

No

I need more information

Would you feel comfortable with the use of an epidural?

Yes

No

I need more information

What is the most important thing about your birth to you?

What is the most important thing about your birth to your partner?

What do you desire most out of Sarahs role as your doula?

Are you open to students and residence in your birth space?

Yes

No

Do you want to touch the baby's head while it is emerging?

Yes

No

Where do you want your partner during the pushing stage?

Are you comfortable with your care provider breaking your bag of water?

Yes

No

Do you want your partner to cut the umbilical cord?

Yes

No

Do you want to do delayed cord clamping?

Yes

No

Do you want the baby to receive erythromycin gel in the eyes after birth?

Yes

No

Do you want the baby to receive a vitamin K injection after birth?

Yes

No

How are you planning on feeding your baby?

Emergency Contacts Name:

Emergency Contacts Phone #

Signature