PreNatal Doula Support - Doula Foundation of Mid America

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Prenatal Questionaire

Your Contact Details

Name: {Required} Age: years old

Partner: Relationship:

Address: Address
, City, State Zip

Phone Numbers: Home
Work
Mobile/Cell

Email Address: {Required}

Estimated Due Date:

Names and ages of other children:

Health Care Information

Physician's Name: Hospital:

Care Provider's Information: Name
Phone
Address
, City, State Zip

Previous: Pregnancies Miscarriages Abortions

Will this be a vaginal birth after cesarean? No Yes, Number of Previous Cesareans Type of Uterine Incision

Do you smoke? No Yes, with no interest in quitting Yes, with interest in quitting

Is there any other information you are seeking to find?

General Information

Give a description of ANY previous labor and delivery experience. If this is your first, please share any other birth stories that stand out to you

Is there ANYTHING you would like to have done differently in your first birth? Please answer separately – mom-to-be and birth partner

Please describe your physical health

How is your pregnancy going? Is it what you expected?

Are you feeling rested? Restless?

List any medications (over-the-counter or prescription) you are currently taking

List any fertility problems, emotional disorders or depression

Have you had any problems with this pregnancy or other pregnancies

What are the most stressful aspects of your life at present? What do you do to counteract this stress?

In general, where do you feel tension in your body?

Who do you turn to for support? How will these people help as you add a new baby to your family?

Has anyone had access to your body without your permission?

Anticipated Birth (please have support person fill this part out with you)

Imagine your ideal birth. What makes it ideal? (BOTH mom and partner answers)

Knowing that birth is sometimes less than ideal, what things in the above scenarios are most important to each of you?

What are your greatest concerns about this birth? (BOTH mom and partner answers)

In the event of an unanticipated cesarean, what things would be most important to you?

Who have you chosen to be with you in labor and why, what will their role be?

What coping techniques for labor do you plan to use?

How do you imagine I can be most helpful to you? (mom and partner answers)

What will be the 3 most important elements of your labor and birth? (mom/partner)

Would you like a mirror so you can view the birth of your baby?

Your Baby

In ideal circumstances, how would you like to welcome your child?

Who will cut the baby’s cord?

If mother and baby need to be separated, shall I remain in the room with the mother/go with the baby while partner stays with mother/other wishes?

Do you have any special concerns about your child?

What are some traits you’ve already noticed about this baby?

Are you planning on breastfeeding?

If you want to breastfeed, do you have FULL support from partner/family members? Were either you or your partner breastfeed?

How often would you like us to be in touch before your baby’s birth? We would like to call any time with questions 4 weeks surrounding the birth.
At the first hint of labor
When anything changes prior to labor beginning
When we decide to go to the hospital/birthing center or active labor begins

Medications you are allergic to

Foods you are allergic to

Non-foods Allergies (eg. Latex)

What are your favorite foods? Anything you don’t like to eat or drink?