Birth Doula Client Intake Form Name * First Name Last Name Email * Job Position Spouse Information Spouse Name First Name Last Name Email Phone (###) ### #### Job Position Client Prenatal Information Do You Know The Sex Of Your baby? Boy Girl We don't know yet We are waiting until the delivery Name of Your Provider Where are you planning to give birth? Hospital Birth Center Home Birth Unsure Name of Your Birth Place is this your first birth? If No, Please tell me about your previous births Yes No If you have had previous births, what were they like? What about those births would you like to be the same or different this time? Do you have any allergies? What are you most excited about for this birth? Your Partner? Have you had any recent illnesses, surgeries, injuries, accidents, or trauma? If yes, please describe below Do you currently take any prescription or non-prescription medication Herbs, natural supplements, vitamins or over the counter ? If Yes, Please describe below Are you taking/will you be taking prenatal classes? Yes No Do you have any specific concerns about your birth? And your partner? Thank you!
