Doula Intake Form - Enci Wellness

Pregnant Person Full Name *

First

Last

Pregnant Person Date of Birth (MM/DD/YYYY)

Pregnant Person Email *

Pregnant Person Contact Number

Partner/Support Person Full Name (if applicable) *

First

Last

Partner/Support Person Email *

Partner/Support person Contact Number

Estimated Due Date (MM/DD/YYYY)

Care Provider *

Birthing Location *

i.e. Home, Hospital, Birthing Center

Birthing Location Address

Address Line 1

Address Line 2

City

State

Zip Code

Have you taken a tour of your birth place?

Yes
Not Yet
It's at home

Please list any medical conditions prior to conception that would impact pregnancy or birth:

Do you have any allergies (food/medication, etc) or food preferences?

Any medical conditions developed during pregnancy?

Other:

How much and how well are you sleeping during this pregnancy?

What number pregnancy is this for you?

Number of previous births:

Please list the number of living children and their ages:

Do you know the gender of your baby?

Girl
Boy
Don't know yet, but plan to find out
It will be a surprise!

Do you have a name picked out? You can share with me here if you would like:

Do you plan to share this name with others before the birth?

Please describe your physical and emotional prenatal and pregnancy experience so far:

Have you taken a childbirth education class? Please list date and location:

Do you plan to take any additional childbirth/newborn education classes? Please list date and location:

Are you and/or your partner/support person reading any books on pregnancy, childbirth, postpartum and breastfeeding? Please list below:

Please check any topics you would like to discuss further:

What is your birth vision? If things go perfectly according to this vision, describe what this looks and feels like for you.

Have you made a birth plan? (If not, we can do this together)

Have you shared your birth plan/preferences with your medical provider?

When does your care provider want you to call them/arrive at the birthing location (in case of a home birth, when does the midwife want to join you)?

Have you discussed protocols with your care provider if you go past your estimated due date?

Please describe any activities you have been doing to physically/mentally prepare for your labor/birth:

i.e. meditation, exercise, breathing, etc

What do you anticipate will be your greatest challenge in labor?

Do you have any persistent concerns/fears regarding your labor?

What do you anticipate will be your greatest source of strength while in labor?

In previously painful or emotionally intense situations (i.e. illness, injury, surgery), what have you found comforting?

Please check any pain management or relaxation techniques that you DO NOT have interest in:

Please list any other techniques you would like to try:

Who would you like to be present during your labor?

Early labor preferences

Other:

Non-medical preferences:

Other:

General labor/birth preferences:

Other:

If your HCP suggests that you have an induction/augmentation, which of the following would you be happy to try?

If you have a scheduled Cesarean Section or your HCP states that you need one, do you want:

Do you have any special choices?

Save placenta
Cord blood

Do you have any spiritual or religious practices that you would like to incorporate into the birth process or directly after the birth? If so, do you need any assistance with any of this?

In what ways do you hope a doula's support will be helpful to you?

Below are some ways I can offer support. What types of assistance do you imagine will be most useful for you?

What is important for you to have during your labor and birth? Feeling loved and supported

Selected Value: 1

1 = unimportant 2-4 = moderately important 5 = very important

Feeling that my wishes are respected

Selected Value: 1

Feeling in control of my labor

Selected Value: 1

Feeling clear-headed and alert during labor

Selected Value: 1

Having the active involvement of my partner

Selected Value: 1

Approaching birth as a spiritual experience

Selected Value: 1

Allowing labor to begin naturally

Selected Value: 1

Avoiding medical interventions

Selected Value: 1

Knowing that medical intervention is available if needed

Selected Value: 1

Feeling minimal pain

Selected Value: 1

Laboring without medication

Selected Value: 1

Using specific learned techniques for relaxation

Selected Value: 1

Being physically active and mobile

Selected Value: 1

Spending early labor at home

Selected Value: 1

Protecting my modesty and privacy

Selected Value: 1

Allowing labor to unfold in its own time

Selected Value: 1

Letting my instincts guide me

Selected Value: 1

Being coached through labor and birth

Selected Value: 1

Experiencing the sensations of birth

Selected Value: 1

Pushing according to my own urges

Selected Value: 1

Seeing or touching my baby's head as it crowns

Selected Value: 1

Bonding with my baby immediately after birth

Selected Value: 1

Other very important things for you during labor/birth:

How does your partner/support person want to be involved in your birth? i.e. hands on, share support with doula or let doula take the lead.

Do you have a postpartum support plan?

Do you have any fears or concerns about the postpartum time?

What method of feeding your baby are you planning to use?

Do you have any issues/fears/concerns about newborn care?

If a hospital birth, do you want your HCP/staff to:

Do you want:

Other:

Please check any topics you would like to discuss further:

Please share anything else you would like me to know about you or any topics you would like to discuss:

Photographic release (If time permits during labor and immediately after the birth, I am happy to take a few candid photos with my phone for you to keep as memories. With your consent, I may share them on my website or social media platforms. Please let me know your preferences below).