Fields in red are required.
About You

Your Partner


People you will have attend your birth

About Your Care Providers
Childbirth Classes? YesNo Breastfeeding Classes? YesNo
About Your Health History
Medical History AnemiaAsthmaAnorexia/BulimiaBladder/Kidney InfectionsBleeding DisordersCancerConization/LEEPDiabetesEpilepsyFibroidsHeart DiseaseHepatitisHerpesHIVHypoglycemiaHyper/HypotensionSTD’sTBThyroid DisordersUlcersVaricositiesVaginal Infections Any history of personal trauma (rape, abuse, etc) YesNo
About Your Pregnancy
Prior Pregnancies Medication, Intervention, and complications
Prior Pregnancies Medication, Intervention, and complications
Prior Pregnancies Medication, Intervention, and complications
Have you breastfed before? YesNo
Have you ever had postpartum depression? YesNo
Have you had an ultrasound? YesNo How Many? Result? Other prenatal screening? Group B Strep? YesNo Gestational Diabetes YesNo
About Your Birth Do you have a birth plan? YesNo Do you want photography or video? YesNo Who will be taking pictures or video? How graphic?
What is your vision for this birth? What are your expectations of your doula? How do you feel about medical procedures/intervention in birth? How do you feel about medical procedures/intervention in birth? Are there any cultural/religious choices/preferences that may affect your birth? Anything else I should know to support you?
Firstname Lastname Age
Jill Smith 50
Eve Jackson 94

Fields in red are required.
About You

Your Partner


People you will have attend your birth

About Your Care Providers
Childbirth Classes? YesNo Breastfeeding Classes? YesNo
About Your Health History
Medical History AnemiaAsthmaAnorexia/BulimiaBladder/Kidney InfectionsBleeding DisordersCancerConization/LEEPDiabetesEpilepsyFibroidsHeart DiseaseHepatitisHerpesHIVHypoglycemiaHyper/HypotensionSTD’sTBThyroid DisordersUlcersVaricositiesVaginal Infections Any history of personal trauma (rape, abuse, etc) YesNo
About Your Pregnancy
Prior Pregnancies Medication, Intervention, and complications
Prior Pregnancies Medication, Intervention, and complications
Prior Pregnancies Medication, Intervention, and complications
Have you breastfed before? YesNo
Have you ever had postpartum depression? YesNo
Have you had an ultrasound? YesNo How Many? Result? Other prenatal screening? Group B Strep? YesNo Gestational Diabetes YesNo
About Your Birth Do you have a birth plan? YesNo Do you want photography or video? YesNo Who will be taking pictures or video? How graphic?
What is your vision for this birth? What are your expectations of your doula? How do you feel about medical procedures/intervention in birth? How do you feel about medical procedures/intervention in birth? Are there any cultural/religious choices/preferences that may affect your birth? Anything else I should know to support you?
Firstname Lastname Age
Jill Smith 50
Eve Jackson 94