Data Collection Form
Email *
I have a Release of Information from my client as part of my personal record keeping *
Doula's name: *
Certification *
Required
Total hours of support provided *
Total length of labor: *
Birthing individual's age: *
Birthing individual's initials: *
Gestation # (pregnancy #) *
Birth # *
Gestational age of baby/babies: *
Baby's/babies' date of birth *
MM
/
DD
/
YYYY
Referral Source *
How many visits did you attend with the birthing individual? *
How many points of contact (phone/email/text) did you have with the birthing individual prior to labor starting? *
After birth, how many visits did you attend with the birthing individual?
How many points of contact (phone/email/text) did you have with the birthing individual after birth? *
Ethnicity of birthing individual *
Required
If other, please specify:
Birth attended by: *
Required
Place of birth *
Required
Name of location:
Was there a transfer? *
Healthcare Provider *
Required
Were there any factors that complicated your client's pregnancy? *
Required
Did the birthing individual attend childbirth education classes? *
Was client's labor induced? *
If client was induced, what methods were used? *
Required
If AROM (artificial rupture of membrane), at what centimeter dilation?
If pitocin used, at what centimeter dilation?
What level of monitoring was used? *
Required
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: *
Required
Medication Used? *
Required
If IV narcotics used, at what cm dilation?
If epidural used, at what cm dilation?
If nitrous used, at what cm dilation?
Where there any complications with labor? *
Required
Birth outcome *
Birth weight: *
Did baby go to the NICU? *
Apgar at 1 min
Clear selection
Apgar at 5 min
Clear selection
Was breast/chest/tissue latch initiated prior to your departure? *
A copy of your responses will be emailed to the address you provided.
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