Doula Client Questionnaire

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Doula Services
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Forms
About Me
More

Please take the time to fill out the entire questionnaire. Be sure to submit before closing this window.

Name *

First

Last

How have you felt during this pregnancy? (physically & emotionally) *

Please describe any abnormal tests, screenings, sonograms or if you have been diagnosed as high risk. *

How have you been preparing for this birth? (reading books, taken classes) *

Describe your goals for this birth. (Unmedicated, water birth, catch own baby, etc.) *

Do you plan on breastfeeding? *

What kind of provider do you have? *

Doctor/OB
Midwife
Family practitioner
Pediatrician
Other

How would you describe your relationship with our provider? *

Is your provider supportive and comfortable with your preferences for pregnancy, labor, birth and newborn care? *

Doula services can be a very hands on and physical type of care/support. Are there any traumatic experiences or triggers that could affect the care you receive from a doula?

What are your expectations with Doula Services? *

How does your partner/main supporter feel about having a doula present for this birth? *

What are coping techniques you can see yourself using during labor and birth? *

Walking
Directed breathing techniques
Spontaneous breathing techniques
Rocking
Massage
Using different positions
Shower/bath tub
Positive affirmations
Prayer
Distractions
Music
Visualization

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