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Prenatal Questionnaire



About You


Name:                                                                 Todays date:                                   


Age:                      Date of birth:


Home address:                                                


Phone (home):                                                              Phone (cell):                                  


Email:                                                                          Occupation:


Partners name:                                               Age:                      Do you have any children:                            


Health Care Providers


Who is your primary care provider:                                             Is this the person who will attend your birth:


If not, what is the name of your OB or midwife:                                


Name of place where you will be giving birth:                                             Phone:                  


If a home birth, what is your backup hospital:                                              Phone:   


Have you/do you plan to take childbirth/breastfeeding classes:           If so, with whom:


Do you have any other health care providers not mentioned:


Support Information



Who will be attending your birth:                                 Plan of care for children during labor/birth:  


What are your primary reasons for wanting a doula:


What are your expectations of your doula:


Do you have any fears/concerns about pregnancy:


Do you have any fears/concerns about birth or postpartum:


Health History


General state of health:


Pregnancy Health:


Any special Concerns regarding your health:


Allergies (drugs, food, latex): 


Diet:                                              Vitamins/supplements/prescriptions:


Do you drink/smoke/ingest drugs:                                    Quantity/Frequency:


Do you exercise/Frequency:                                           Do you/have you had any STD's/STI's:


Any major surgeries, injuries, hospitalizations:


Do you have a history of emotional/psychological problems:


Your Pregnancy


In pre-pregnancy do you suffer from PMS:            


If so, what are your symptoms:                                        Coping techniques:


Is this a planned Pregnancy:                       How do feel now about it: 


What is your expected duedate:                               


Any previous pregnanies:                             Miscarriages:                                   Live births:     


Prior pregnancies:


       Date of birth    #Weeks at birth    Sex    Weight      Name/outcome      Labor length       Meds/intv/compl.










Pain management:                                                      Coping techniques:                         


Interventions (fetal monitering, induction, episiotomy, c-section etc.):


Have you breastfed before:                                Any problems:  

Have you ever had/are you concerned about having postpartum depression: 

Have you had/do you plan on having an ultrasound: 


Do you want to know the sex of your baby before birth:


Do you want your placenta encapsulated/would you like information about placenta encapsulation:


Your Birth


What is your vision for this birth:




Where in your body do you usually feel tension: 


How do you manifest tension (check all that apply):   difficulty breathing              sweating            panic            nausea        

moaning       grinding teeth          clenching fists          racing heart          anxiety         any other:     


How do you find comfort when experiencing stress/pain (check all that apply):  distraction         movement        silence      


turning inward     self-medicating behaviors (OTC meds etc.)        hot/cold packs       companionship       Any other:        


What is your plan for coping while in labor: 


How do you feel about medical procedures/intervention in birth:


How would you like your doula to respond if you are requesting pain medications:




Do you have a birth plan:                If not, would you like to learn more about them:


Do you want photography/video during your labor/birth:             If so, who will be taking pictures/video:     


Are there any areas of of your or your babies body you do not want photographed/filmed:


Are there any cultural/religious choices/preferences that may affect your labor/birth:




Do you have anything to add:





Thank you for taking the time to fill this out! 


(all responses are optional and will be kept strictly confidential)  

Sharon Jong, 






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