What's in a form

I have gotten a few requests to share information about Doula Intake forms.
I don't know what other doula orgs do, but ALACE gives out a massive general form that is really really overwhelming (to me at least). In my doula practice, I whittled the form down to bare essentials with a lot of room for additional note-taking and found it worked great. I am happy to share a sample form with you. It is not formatted, but gives you the information to go create your own. I will post ore on other types of forms in the near future. I also welcome feedback on what is missing or needschanging in this form! Enjoy:

Creative Birth Doulas
Client Intake Form

ABOUT YOU:

CLIENT NAME DOB
OCCUPATION

PARTNER DOB
OCCUPATION

ADDRESS
CITY STATE ZIP CODE
HOME PHONE CELL/WORK PHONE
ALT PHONE ALT PHONE

RELATIONSHIP AND FAMILY INFORMATION:
HOW LONG HAVE YOU BEEN TOGETHER AND HOW DID YOU MEET?



FATHER OF BABY (if other than partner)

HOW MANY CHILDREN DO YOU HAVE? PLEASE LIST SIBLINGS NAMES AND AGES:


PETS?

OTHERS WHO LIVE IN HOUSEHOLD (names and relation to you, please)?


WHO REFERRED YOU TO OUR SERVICES?


ABOUT YOUR HEALTH CARE PROVIDERS:
PRIMARY CARE PROVIDER (ie, your doctor or midwife):
TYPE OF PRACTICE (Private, HMO, Group…): PHONE:
PLANNED PLACE OF BIRTH:
BACK UP HOSPITAL (if you are planning to give birth at home or a birth center):
If hospital/birth center:
HAVE YOU TAKEN A TOUR? REGISTERED?

BABY’S HEALTH CARE PROVIDER: PHONE:
HAVE/WILL YOU TAKE(N) CHILDBIRTH EDUCATION CLASSES?
IF SO, WITH WHOM? WHEN?
BREASTFEEDING CLASSES? WITH WHOM? WHEN?
OTHER PRENATAL CLASSES? (ie, yoga, infant cpr…)
OTHER HEALTH CARE PROVIDERS YOU SEE (ie, acupuncturist, naturopath, therapist, etc…)
FEELINGS/QUESTIONS/CONCERNS ABOUT THE CARE YOU ARE RECEIVING?


CLIENT’S HEALTH HISTORY:
HOW IS YOUR HEALTH?
ANY ALLERGIES?
WHAT IS YOUR DIET? (vegetarian? Special needs?)
VITAMINS/SUPPLEMENTS?
ROUTINE OR OTC MEDICATIONS?
DO YOU DRINK ALCOHOL? QUANTITY/FREQUENCY
DO YOU SMOKE? QUANTITY/FREQUENCY
PRESENT EXERCISE AND FREQUENCY
ARE YOU CURRENTLY RECEIVING CARE FOR ANY HEALTH ISSUES?
IF SO, FOR WHAT?
HOW IS YOUR MENTAL AND EMOTIONAL HEALTH?

OPTIONAL: DO YOU HAVE ANY HISTORY OF PERSONAL TRAUMA (ie, abuse, assault, or anything else you want to discuss as we prepare a safe space for your birth experience)?
ANYTHING ELSE YOU WANT TO SHARE ABOUT YOUR PHYSICAL AND/OR EMOTIONAL HEALTH AS RELATED TO YOUR PREGNANCY AND BIRTH?




FAMILY INFORMATION:
CLIENT, WHERE DOES YOUR FAMILY LIVE?
PARTNER (if applicable), WHERE DOES YOUR FAMILY LIVE?
PLEASE BRIEFLY DESCRIBE YOUR RELATIONSHIP WITH YOUR AND YOUR PARTNER’S FAMILIES:

PLANS FOR FAMILY TO BE INVOLVED WITH BIRTH OR POSTPARTUM PERIOD?
ANY RELEVANT INFORMATION YOU WOULD LIKE YOUR DOULA TO KNOW OR UNDERSTAND ABOUT FAMILY OR FRIENDS INVOLVED IN THE BIRTH PROCESS?

CURRENT PREGNANCY/CHILDBEARING HISTORY:
WAS THIS A PLANNED PREGNANCY?
HOW DO YOU FEEL ABOUT THIS PREGNANCY?
WHAT IS YOUR ESTIMATED DUE DATE (EDD)?
HAVE YOU BEEN PREGNANT BEFORE? HOW MANY TIMES?

HAVE YOU GIVEN BIRTH BEFORE? HOW MANY TIMES?
HOW MANY CHILDREN DO YOU CURRENTLY HAVE?
HAVE YOU BREASTFED BEFORE? IF SO, ANY SPECIAL CONCERNS FOR THIS
TIME?
HAVE YOU EVER HAD POSTPARTUM DEPRESSION? MOTHER/SISTERS?




CIRCLE ANY THAT APPLY FOR THIS PREGNANCY:
INDIGESTION FATIGUE/TIREDNESS MUSCLE CRAMPS
ANXIETY HEMORRHOIDS NAUSEA/VOMITING
CARPAL TUNNEL SYNDROME INCONTINENCE SHORTNESS OF BREATH
CONSTIPATION, DIARRHEA LACK OF SLEEP SWELLING

ANY MEDICAL COMPLICATIONS THIS PREGNANCY?





ABOUT YOUR BIRTH (feel free to use as much space as you need to answer questions):
MOTHER: WHAT IS YOUR VISION FOR THIS BIRTH? (PLEASE BE SPECIFIC):








PARTNER (if applicable):WHAT IS YOUR VISION FOR THIS BIRTH? (AGAIN, PLEASE BE SPECIFIC):







WHAT ARE YOUR EXPECTATIONS OF YOUR LABOR ASSISTANT/DOULA PROVIDER?






WHAT IS YOUR PLAN FOR COPING WITH THE INTENSITY OF LABOR? ANY SPECIAL IDEAS ABOUT WHAT YOU MIGHT LIKE FOR LABOR (ie, massage, aromatherapy, special snacks…) OR ARE THERE ANY SPECIAL POSITIONS OR TECHNIQUES YOU WOULD LIKE TO USE?






PLEASE BRIEFLY DESCRIBE YOUR PREGNANCY AND BIRTH HISTORY IN YOUR OWN WORDS (if applicable):




DO YOU HAVE ANY EMOTIONAL OR PHYSICAL ASPECTS OF PREPARATION FOR BIRTH YOU WOULD LIKE SPECIAL ATTENTION, INFORMATION, OR SUPPORT FOR?






DO YOU HAVE A BIRTH PLAN? REVIEWED WITH CAREGIVERS?
IF YOU HAVE A BIRTH PLAN, PLEASE MAKE SURE TO GET A COPY TO YOUR DOULA!


ANYTHING ELSE YOU WOULD LIKE YOUR DOULA TO BE AWARE OF TO PROVIDE THE BEST SUPPORT POSSIBLE DURING YOUR LABOR AND BIRTH?







THANK YOU!