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About You
Name
*
Email
*
Phone
*
Birthdate
*
Address
*
Address
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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Texas
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Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Who referred you to the doula program?
*
Angel Coleman
Tomesha Walker
Jazmynn Montanez
Other
Other
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
Other
Other
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
Other
Other
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
*
Today's date
*
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