Birth Doula Intake | Okanagan Doula

Birth Doula - Intake Form

BIRTHING PERSON * Applicant

First Last

Phone

Email(Required)

Birthday

Do you identify as Aboriginal?

You may be eligible to for grant through The Doulas for Aboriginal Families Grant Program (DAFGP)

Yes

Occupation

Physical Address

Street Address City Province Postal Code

Mailing Address

Street Address City Province Postal Code

Your Birthing Partner

Do you have a birthing partner?

Yes

Is your birthing partner also your spouse?

Yes

Spouse Information

Spouse - Do you identify as Aboriginal?

You may be eligible to for grant through The Doulas for Aboriginal Families Grant Program (DAFGP)

Yes

Spouse's Name

First Last

Spouse's Email

Spouse's Phone

Spouse's Occupation

Spouse's Birthday

Spouse - Do you smoke?

Currently

In The Past

Spouse - Do you have any blood-borne illnesses or infectious diseases?

Yes

Spouse - Please list any blood-borne illnesses or infectious diseases

Spouse - Do you currently, or have you in the past, used any prescription or recreational drugs?

Currently

In The Past

Spouse - Do you have a history of experiencing any physical, mental or verbal abuse?

Yes

Spouse - Have you been diagnosed or do you experience any mental health issues?

Yes

Spouse - Have you been diagnosed with any medical health issues?

Yes

Birthing Partner Info

Birthing Partners' Name

First Last

Birthing Partners' Phone

Birthing Partners' Email

What is the nature of your relationship with your Birthing Partner?

Birthing Person's General Information

Estimated Due Date

Is this your first pregnancy & birth?

Yes

Emergency Contact (Name & Phone):

Family Doctor

Health Care Provider & Team

Is this your first pregnancy & birth?

Have you had any other children?

Yes

Will your other children be at the birth?

Yes

What plan do you have for childcare?

Are the other children living in the home?

Yes

Periodically

Do you smoke?

Currently

In The Past

Have you had any previous surgeries? Complications?

Do you have any allergies (food, medications, etc) or illnesses (chronic or otherwise?)

Do you have any medical issues? Are you taking medications? If so, what are they, what dose and what are they for?

Any restrictions placed on you by your caregiver?

Do you have any prenatal complications with this pregnancy?

Do you have any blood-borne illnesses or infectious diseases?

Yes

Please list any blood-borne illnesses or infectious diseases.

Do you have a history of experiencing any physical, mental or verbal abuse?

Yes

Do you currently, or have you in the past, used any prescription or recreational drugs?

Currently

In The Past

Have you been diagnosed or do you experience any mental health issues?

Yes

Have you been diagnosed with any medical health issues?

Yes

Do you have a good support system:

Yes

Did you take prenatal classes? If so where/instructor?

Yes

Where was the prenatal class and who was the instructor?

Birth Preferences

Where do you plan to have your baby?

Hospital

Home

Other

Other Birthing Location

Street Address City Province Postal Code

Hospital Birth - would you like to labour at home or in hospital?

Yes

Do you want us to help you:

At home?

Meet you at the hospital?

Home Birth - Are you planning a land or water birth?

Yes

Placenta Preferences

How do you see us working together?

Does your birthing partner want to provide support with our assistance? Or will we be the primary support person?

What is your vision for this birth?

Do you, or your birthing partner, have any fears?

In the event of a cesarean, who would you like to accompany you?

Birthing Partner

Doula

(Only one support person allowed)

Do you feel comfortable voicing your needs to us?

Do you feel comfortable voicing your needs to your caregivers?

Are you okay with touch?

Yes

Sometimes

Comfort Measures

COMFORT MEASURES - Labour Tub/Shower

COMFORT MEASURES - Walking

COMFORT MEASURES - Birth Ball

COMFORT MEASURES - Massage/Counter Pressure

COMFORT MEASURES - TENS

COMFORT MEASURES - Entinox (Laughing Gas)

COMFORT MEASURES - Pain Medication(Fentanly/ Morphine)

COMFORT MEASURES - Epidural

GOING INWARD - Visualization/Imagery

GOING INWARD - Relaxation

GOING INWARD - Quiet/Dark Room

GOING INWARD - Concentration

GOING INWARD - Meditation

GOING INWARD - Hypnonosis

GOING INWARD - Hypno-Birthing

GOING INWARD - Prayer

DISTRACTION - Music

DISTRACTION - Watch TV/Movie

DISTRACTION - Talk & Have Conversations

DISTRACTION - Activities (Baking, Play Games etc)

DISTRACTION - Laughter/Jokes

Medications

If you would like to use medication for pain management, what are your preferences?(Analgesics: Morphine, Fentanyl, Nitrous Oxide; Epidural; Other) Reason for your preference?

Is there any positions that you would rather avoid, or that may be difficult for you?

What kinds of foods do you eat? Enjoy/Dislike? Allergies?

Is there any smells that you enjoy/not enjoy?

Who will be attending the birth? (birthing partner, family, etc..)?

Will they be in the delivery room with you, or in the waiting room and will need to be informed?

Is there anybody who is not welcome at the birth who may show up unexpectedly (Family, friends, etc..)?

Anybody who will be present at the birth have any health concerns or fears that may cause physiologic issues? (Diabetes, fainting, nausea, etc.)

Do you want pictures/video of your labour/birth/immediate postpartum?

Yes

Birth Photographer? What should be included?

How did your mother’s birth(s) go with you (and/or siblings)?

Have you had any past trauma that may play a role in you birth? Would you like to discuss it?

Postpartum Preferences

Would you like to catch the baby?

Yes

Would your partner like to catch the baby?

Yes

Would you like to cut the cord?

Yes

Would your partner like to cut the cord?

Yes

Newborn procedures?

Physiological cord clamping, eye prophylaxis, vitamin K [shot/oral, sugar water], cord blood banking, cord burning?

Will you be breastfeeding or formula feeding ? What are your feelings about formula supplementation (in hospital, and out)?

Do you have any concerns about your feeding experience?

Are there any cultural or religious traditions that will be performed at any point? Anything that we can assist you with?

What does your support system look like at home for after you have the baby? Names of support people & dates of arrival?

(partner working or time off, family living in town, family coming from out of town, postpartum doula support, etc..)

Would you like any postpartum doula support?

Yes

Maybe

One home visit in the first few days is included in your birth doula package.

Anything in particular, not mentioned above that you would like to share with us or that we should share with our backup doula?

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