Data Collection Form
Doula's name: *
Your answer
Certification *
Total hours of support provided *
Your answer
Total length of labor: *
Your answer
Birthing individuals age: *
Your answer
Birthing individuals initials: *
Your answer
Gestation # (pregnancy #) *
Your answer
Birth # *
Your answer
Gestational age of baby at delivery: *
Your answer
Date individual delivered/baby's date of birth *
MM
/
DD
/
YYYY
Referral Source *
How many visits did you attend with the birthing individual? *
Your answer
How many points of contact (phone/email/text) did you have with the birthing individual prior to labor starting? *
After delivery, how many visits did you attend with the birthing individual?
Your answer
How many points of contact (phone/email/text) did you have with the birthing individual after delivery? *
Ethnicity of birthing individual *
If other please specify:
Your answer
Birth attended by: *
Place of birth *
Healthcare Provider *
Were there any factors that complicated your client's pregnancy? *
Did the birthing individual attend childbirth education classes? *
Was client induced? *
If client was induced, what methods were used? *
If AROM (artificial rupture of membrane), at what centimeter dilation?
Your answer
If pitocin used, at what centimeter dilation
Your answer
What level of monitoring was used? *
Were antibiotics administered? *
If yes to above, for what reason (select all that apply)
Method of delivery: *
Was the birthing individual attempting a Vaginal Birth after Cesarean? *
Comfort measures used: *
Medication Used? *
If IV narcotics used, at what cm dilation?
Your answer
If epidural used, at what cm dilation?
Your answer
If nitrous used, at what cm dilation?
Your answer
Where there any complications with labor? *
Birth outcome *
Birth weight: *
Did baby go to the NICU? *
Apgar at 1 min
Apgar at 5 min
Was breast/chest/tissue latch initiated prior to your departure? *
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