Doula Client Questionnaire
Name of Mother and Partner *
Your answer
Birth Location *
Your answer
Care Provider *
Your answer
Home Address & Contact Number *
Your answer
Estimate Due Date *
MM
/
DD
/
YYYY
What are you feeling about your upcoming labor and birth? *
Your answer
What do you fear most? *
Your answer
When you are in pain or frustrated, what kinds of personal comforts work for you? *
Your answer
What types of words of support generally work for you? Are there any verbal cues that you do not feel comfortable with? *
Your answer
Have you had any emotional, physical or sexual trauma in your past? We can discuss this more or not discuss it, but feel free to initiate dialogue at any point.
Do you want to discuss it or receive additional resources?
Your answer
Is there any religious or cultural traditions that directly impact the birth experience?
Your answer
Do you currently have any communicable diseases? *
Your answer
Is there any specifically that you would like me to cover in our prenatal visits? Any concerns? *
Your answer
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