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YVR DOULA SERVICES
Prenatal Education/
Birth and Postpartum Support
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YVR DOULA INTAKE FORM
First name
*
Last name
*
Partners name (if applicable)
*
Email
*
Phone number
*
Partners phone number
*
Address
*
Buzzer number or entry details
*
Due Date
*
Care Provider
*
Planned place of birth
*
Who else will attend the birth?
Gender of baby
Boy
Girl
Surprise
Group B strep result
Negative
Positive
Not tested yet
Do you have a backup doula? If so, who?
Back up Doulas phone #
Have you attended childbirth classes?
Yes
No
If so, with whom?
How has the pregnancy been so far?
Any food allergies or restrictions?
Do you have any birth ceremonies or special requests?
Would you like any photos or videos taken during the birth?
Yes
No
Would you like to take the placenta home?
Yes
No
Are you on SSRI medication for anxiety or depression?
Yes
No
Are you working with supporting care providers?
Acupuncturist
Massage Therapist
Chiropractor
Pelvic floor Physiotherapist
Lactation Consultant
Other
Have you had previous pregnancies or births? If so, what are the child(ren) names and ages? Lengths of births?
Would you feel comfortable with non-medicated comfort measures such as TENS machines, Robozo, hydrotherapy, or sterile water injections?
Yes
No
I need more information
Would you feel comfortable with the use of nitrous oxide?
Yes
No
I need more information
Would you feel comfortable with the use of narcotics such as morphine/ fentanyl?
Yes
No
I need more information
Would you feel comfortable with the use of an epidural?
Yes
No
I need more information
What is the most important thing about your birth to you?
What is the most important thing about your birth to your partner?
What do you desire most out of Sarahs role as your doula?
Are you open to students and residence in your birth space?
Yes
No
Do you want to touch the baby's head while it is emerging?
Yes
No
Where do you want your partner during the pushing stage?
Are you comfortable with your care provider breaking your bag of water?
Yes
No
Do you want your partner to cut the umbilical cord?
Yes
No
Do you want to do delayed cord clamping?
Yes
No
Do you want the baby to receive erythromycin gel in the eyes after birth?
Yes
No
Do you want the baby to receive a vitamin K injection after birth?
Yes
No
How are you planning on feeding your baby?
Breastfeeding
Formula feeding
Donor milk
Bottle feeding
See how it goes
Emergency Contacts Name:
Emergency Contacts Phone #
Signature
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