


HeartRoots
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.
#1
#2
#3
#4
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!