Birth Doula Intake Form - Mother
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| Contract (including Payment, Cancellation and Refund Policies)
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I have read and agree to the terms and conditions as set out in the Letter of Agreement Describing Doula Services (document can be found online at http://AdarBirthServices.com/Letter-of-Agreement-Describing-Doula.doc). I am a client of SCBP; this contract does not apply to me. I have not yet chosen my Doula; the contract will come into effect if and when I inform Adar Birth Services that I have chosen one of their birth doulas. If you have concerns or questions about the terms outlined in the Letter Describing Doula Services, please contact Adar Birth Services before agreeing.
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| Name
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| My Birth Partner's Name (if none, please write, n/a")
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| Date of Birth
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| Email
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| Home Address
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| Special instructions for getting to your home.
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Please include any special instructions, such as buzzer number, parking tips or details about how to get to your home if it is at all difficult.
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| Phone 1
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| Phone 2
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Please make it easy for us to get ahold of you should we need to.
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| Estimated Due Date
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| Is this your first pregnancy?
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Yes No
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| If no, what was the outcome of your previous pregnancy/pregnancies?
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| Are you carrying multiples?
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Yes No
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| Where do you plan to give birth?
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Home BC Women's St Paul's Richmond Lions Gate Royal Columbian Burnaby General Surrey Memorial
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What is (are) the name(s) of your primary prenatal healthcare provider(s)?
Please also indicate their profession (midwife, OBGYN, GP) and their clinic name (if applicable).
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| Please check any of the following that you are experiencing:
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varicose veins doctor- or midwife-prescribed bedrest nausea/vomiting aversion to certain smells pregnancy-induced hypertension (PIH) vaginal bleeding abdominal cramping edema/swelling violent headaches and vomiting, visual distubances of spots and flashing lights and/or convulsions persistent, severe mid-back pain that is not temporarily helped with a change in position
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| Details regarding above
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| Do you feel foetal movements?
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Yes No Not sure
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| If yes, has there been any change?
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| How are you feeling about your pregnancy right now?
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| How do you feel about becoming a parent? Or, if you are already a mother, how do you feel about becoming a parent again?
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| Tell me about some of your fears around the birth.
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If you can't think of any fears, please tell me what things you may have heard from other parents about their birth that has made you feel badly for them.
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| If you could labour and birth anywhere in the world and in any setting, not having to worry about safety for you, your partner or the baby, where would your fantasy birth take place? Who would be supporting you and what would they do?
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Whether hospital, home or some other planet altogether, whatever feels true for you is the right answer.
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| Please tell me what else you would like me to know to help you in your pregnancy, labour, delivery and postpartum period.
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| I plan to
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Breastfeed exclusively Pump my milk and feed with a bottle Formula feed Other (please desribe below)
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| Details
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| I feel ________ about my feeding choices.
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Confident Middling Not confident
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| Diapering
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Confident Middling Not confident
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| Bathing
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Confident Middling Not confident
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| Dressing
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Confident Middling Not confident
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| Playing
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Confident Middling Not confident
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| Interaction/communication
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Confident Middling Not confident
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| Common infant health issues (e.g. colic, thrush, jaundice)
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Confident Middling Not confident
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| Coping with stressful times (e.g. crying, fussing, screaming, exhaustion)
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Confident Middling Not confident
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| Use of carseat
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Confident Middling Not confident
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Image Verification
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