Doula Client Questionnaire
Name of Mother and Partner *
Birth Location *
Care Provider *
Home Address & Contact Number *
Estimate Due Date *
MM
/
DD
/
YYYY
What are you feeling about your upcoming labor and birth? *
What do you fear most? *
When you are in pain or frustrated, what kinds of personal comforts work for you? *
What types of words of support generally work for you? Are there any verbal cues that you do not feel comfortable with? *
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?
Is there any religious or cultural traditions that directly impact the birth experience?
Do you currently have any communicable diseases? *
Is there any specifically that you would like me to cover in our prenatal visits? Any concerns? *
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