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*
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Client Information
Name
*
First
Last
Date of Birth
*
Age
*
Due Date
*
Address
*
Street Address
City
State
Zip Code
Email Address
*
Phone No.
*
Emergency Contact
Name
*
First
Last
Relationship
*
Phone No.
*
Care Provider Details
OBGYN / Midwife Name
*
Delivery Location
*
Home
Birth Center
Hospital
Not Sure Yet
Delivery Location Name
*
Delivery Location Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Have you figured the delivery location?
*
Yes
No
Do you have health insurance?
*
Yes
No
Did you choose your care provider specifically?
*
Yes
No
Are you comfortable with your care provider?
*
Yes
No
Birth Plan Preferences
Preferred Birth Location
*
Preferred Birth Type:
*
(e.g., vaginal, water birth, C-section)
Are you planning to use any pain management methods?
*
(e.g., epidural, natural pain relief, etc.)
Are there any specific birth practices or rituals you wish to follow?
*
(e.g., delayed cord clamping, immediate skin-to-skin contact, etc.)
Who do you want to be present during labor and delivery?
*
Any preferences or concerns about interventions?
*
(e.g., induction, episiotomy, etc.)
Do you have a written birth plan?
*
Yes
No
Emotional & Informational Support
Have you attended any childbirth education classes?
*
Yes
No
Are you interested in additional resources or classes?
*
(e.g., breastfeeding support, newborn care, etc.)
What are your biggest concerns or fears about labor and birth?
*
What kind of support do you find most helpful?
*
(e.g., physical touch, verbal encouragement, etc.)
Current Pregnancy Details
Expected Due Date
*
Number Expecting
*
Baby Gender
*
Boy
Girl
Not sure yet
It’s a surprise!
Have you chosen a name?
*
Not yet
Yes!
If Yes, Name:
*
Will you be sharing the baby’s name with others?
*
Yes
No
Overall, how has your pregnancy been so far?
*
How much sleep have you been getting each night? Are you experiencing any difficulties at times?
*
Do you currently have pregnancy-related health conditions?
*
Subchorionic Hematoma
Hyperemesis Gravidarum
Pre-Eclampsia
Low Birth Weight
Rh Incompatibility
Intrauterine Growth Restriction
Polyhydramnios
Oligohydramnios
None of These
Do you have any pregnancy-related health conditions?
*
Preterm Labor
Gestational Hypertension
Gestational Diabetes
Placenta Previa
Genetic Disorder
Macrosomia
Group B Strep
Vena Cava Compression
Pica
None of these
Please check all that apply.
Please inform us of any pregnancy-related conditions that haven't been mentioned above.
Previous Pregnancy Details
Which pregnancy number is this for you?
*
Please enter a number greater than or equal to
1
.
How many previous births have you had?
*
Please enter a number greater than or equal to
0
.
Of your previous pregnancies, how many were carried to term?
Of your previous pregnancies, how many were pre-term?
*
Have you experienced any of the following types of births?
*
This will be my first birth
Vaginal
Caesarian Section
Induction for Medical Reasons
Home Birth
Hospital Birth
Please select all that apply.
Have you experienced any of the following types of birth?
*
VBAC
Elective Induction
Birth Center Birth
Water Birth
None of These
Please select all that apply.
How many children do you have?
*
This will be my first child
This will not be my first child
Please list their name and ages below.
Name
Age
Add
Remove
How long was your previous labor?
*
Do you currently have pregnancy-related health conditions?
*
Subchorionic Hematoma
Hyperemesis Gravidarum
Pre-Eclampsia
Low Birth Weight
Preterm Labor
Gestational Hypertension
Gestational Diabetes
Placenta Previa
Pica
Rh Incompatibility
Intrauterine Growth Restriction
Polyhydramnios
Oligohydramnios
Macrosomia
Group B Strep
Vena Cava Compression
Genetic Disorder
None of the above
Select all that apply or none.
Do you have any allergies?
*
Yes
No
Please provide list of allergies.
*
Name
Reaction
Add
Remove
Postpartum Information
Do you have any postpartum plan?
*
Yes
No
Do you plan to breastfeed, formula feed, or both?
*
What kind of postpartum support do you anticipate needing?
*
(e.g., lactation consulting, meal prep, emotional support, etc.)
Any known issues with postpartum depression or anxiety in your personal or family history?
*
Postpartum Goals
What are your top three goals for the postpartum period?
*
Add
Remove
(e.g., establish breastfeeding, get adequate sleep, recover physically, etc.)
Additional Details
Anything that wasn't covered in this intake form that you'd like to share.
Consent
*
I Agree to Grant Information Access
I hereby grant consent to Alexandria Beyn for the collection and utilization of my personal information exclusively for the provision of doula services. I acknowledge that all shared information will be treated with utmost confidentiality and solely utilized for my welfare and assistance.
Client Signature
*
Today's Date
*
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