EmailMe Form - Getting to Know You Better

Your Primary Doula *

Your Name *

Your Age

Estimated Due Date

MM / DD / YYYY

Cell Phone Number

### - ### - ####

Alternate Phone Number

### - ### - ####

Email

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Partner's Name

Partner's Cell Phone Number

### - ### - ####

Partner's Email

Who will accompany you during the birth?

Who is your OB / Midwife?

Where will you give birth?

Are you having a boy or a girl? Does the baby have a nickname?

Do you have any pets? Please tell me about them.

What do you and your partner do for a living? Does anything about either of your careers affect your pregnancy? (physically, stress, long hours, etc.)

Do you have a Religious affiliation or any special customs that you would like me to know about?

I'd like to receive handouts...

on paper

by email

Do you have any allergies I should know about?

Have you had any surgeries (incl. cryosurgery, LLETZ, LEEP) or traumas (birth, sexual, abuse, etc.) that may affect your labor?

Do you have a history of mood disorders or depression? If so when and what treatment did you receive? Are you currently taking medication for this?

Have you received information about...

Please list all prenatal classes taken in preparation for your birth (childbirth prep, breastfeeding, babycare, yoga, dance, etc.) Was there anything you learned in your childbirth preparation classes that you have especially liked? Anything you didn't like? Would you like any recommendations?

Please list any medications, herbs, homeopathy or vitamins you are taking

Are you utilizing any therapies?

Homeopathy

Massage

Acupuncture

Chiropractic

Any other therapies? Do you dislike any of the above therapies?

What is your exercise routine now? Has it changed, if so how?

How has your pregnancy been? Any complications or considerations?

Any concerns about your pregnancy or postpartum period?

How are you taking OTC medications for common illnesses (cold, headaches, pain) when you are not pregnant? Do you prefer OTC or natural alternatives?

Getting to Know Your Birth Wishes Better

The following questions will help me to get a clear understanding of your ideal birth as well as helping you sort out your thoughts and wishes about your upcoming birth. Sometimes during this exercise parents realize that the options they have lined up for their upcoming birth will not meet their needs and wishes. Let me know if that happens and I can provide resources for alternative caregivers or facilities that might better meet your needs. I feel that every woman deserves a birth the way she wants it.

Imagine you are having your perfect labor and everything proceeds exactly as you imagine it to be. What does that look like to you? Keep the following thoughts in mind as you answer the questions below.

*When and where does labor being?
*Who is with you when labor begins?
*How quickly do your contractions progress?
*How long do you push?
*How does your care provider assist you?
*Where do you labor?
*Where do you give birth?
*What tools do you use to cope with labor?
*Who labors with you?
*What techniques are NOT a part of your labor?
*What happens after the baby is born?

Do you have faith in your body and trust that you instinctively know how to give birth?

Yes

No

Not sure

If no or unsure, please explain.

What are your expectations about this birth?

What are your fears or anxieties?

What are your wants and desires?

How would you rate your communication with your medical care provider

What role do you see your partner playing during labor? Is there anything you really want your partner to do? Anything you don't want partner to do or see?

What are you expecting from me during labor? Is there anything you really want me to do? Anything you don't want me to do or see?

What would you like to focus on in our prenatal appointments?

For me, the best approach to pain relief and coping techniques are...

What kind of encouragement or motivation do you best respond to? How strongly would you like me to encourage you to achieve the goals we will talk about?