Labor Support Services, Susan Miller, CD, DONA, Birth Doula

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Client Questionnaire Form

Mother's Name:

Partner's Name:

Address: :

Zip Code:

Home Phone:

Mobile Phone:

Partner's Work Phone:

Partner's Mobile Phone:

Email Address:

Mother's Occupation:

Partner's Occupation:

Due Date:

Name of Dr/Midwife:

Birth Site:

Names of Other Family Members, Ages and Relationship:

Do you have pets?

Please describe any conditions that affect the way you are feeling and/or coping with this pregnancy:

What medications are you taking now (including vitamins, iron, etcetera)?

Whom have you chosen to be with you for this labor and birth?

What things are most important to you in terms of this birth experience?

What do you want from your partner in terms of support during your birth experience?

What do you want from me as your labor support during your birth experience?

Check as many as you feel apply:

When you tense up for whatever reason, where do you feel the tension first?

Jaw Neck Hands Legs Shoulders Hips

What other signs of tension or stress does your body exhibit?

In painful situations, how do you comfort yourself?

Deep breathing	Concentrating on something else	Making noise
Rocking	Turning inward

In labor, what coping techniques do you think you will use?

Other:

Have you taken childbirth education classes in the past?

Do you plan to take childbirth classes during this pregnancy?

What questions or concerns do you have that we need to deal with before labor starts?

Do you know your baby's gender?

If you have chosen a name for your baby, what is it?

If you have a boy, do you plan to have him circumcised?

In the hospital do you plan:

How do you plan to feed your baby?

What arrangements have you made for help at home during the postpartum period?

Is there anything else you feel I should know in order to help you?

14500 Cutten Road #1208 \| Spring, Texas \| 832-368-9669 \| susan@houstondoula.com
© Copyright 2003 Labor Support Services, Susan Miller, CD (DONA), Birth Doula