Doula Screening - Cornerstone Pregnancy Services

About You

Name *

Email *

Phone *

Birthdate *

Address *

Address

City

State/Province

Zip/Postal

Who referred you to the doula program? *

Angel Coleman

Tomesha Walker

Jazmynn Montanez

OtherOther

Partner's name (whoever will be in the labor room)

Partner's phone number (whoever will be in the labor room)

Your Family

List other children's names and ages (If you don't have any other children, please indicate 'None'.) *

Others in household (name and age)

Plan for care of children during labor

Plan for care of pets during labor

Medical History

This information will not be shared.

Primary OB/GYN or midwife contact information (name, number, medical facility)

Place of birth *

University Hospital MacDonald

MetroHealth

Fairview Hospital - Cleveland Clinic

St. John Medical Center - University Hospital

Southwest General Health Center - University Hospital

Parma Hospital - University Hospital

Hillcrest - Cleveland Clinic

Mercy Health

OtherOther

Your Pregnancy

General Information about your pregnancy

Estimated due date OR first day of last menstrual period (Please state which.) *

How many weeks pregnant are you currently? *

Multiples? *

Yes

No

High Risk? *

Yes

No

Any pregnancy complications? If so, what kind?

Concerns about pregnancy? *

Any previous pregnancy complications? If so, what kind?

Number of previous pregnancies

Past miscarriages? If so, how many?

Number of live births *

Birth History

History of postpartum depression/anxiety/psychosis? *

Yes

No

Maybe

OtherOther

List previous births (date, duration of labor, medical intervention, pain medication) *

Birth Plan

How labor will proceed? *

Planned induction

Planned ceserean

Spontaneous labor/vaginal

VBAC (Vaginal Birth after Ceserean)

Pain management plan *

Skin to skin? *

Yes

No

Not sure

Plan to breastfeed? *

Yes

No

Maybe

Delayed cord clamping? *

Yes

No

Maybe

Delay weighing and other medical procedures? *

Yes

No

Media

Video

Pictures/photographer

Music

Movie

Anything to add to your birth plan?

Resources

Have you taken a childbirth class? *

Yes

No

Would you like more information on a childbirth class? *

Yes

No

Planning to/already scheduled

Have you taken a class on breastfeeding?

Yes

No

Do you need more information on a breastfeeding class? *

Yes

No

Do you need clothing resources?

Yes

No

Maybe

Do you need carseat resources or information?

Yes

No

Maybe

Do you need pediatrician resources?

Yes

No

Maybe

Do you need information on breastfeeding or other mom related support groups?

Yes

No

Maybe

Do you have questions about any medical procedures?

Do you have any questions about pregnancy or child birth?

Do you have any concerns about your medical caregiver?

Is there anyone that should not be in the room?

Do you have any mental health concerns or past trauma? *

Why do you want a doula?

Your signature *

By giving us your contact information and signature, you are indicating that it is OK for us to call, email, or text.

May we leave a message? *

How would you prefer we identify ourselves when we contact you? *

Cornerstone

Jesse

Pregnancy Center

Today's date *