Please complete this form in its entirety. This will provide me with insight on your goals for your labor and the delivery of your baby. We will discuss more in detail during the in home consultation. Labor Doula Questionaire * indicates required fields *Expected Mommy's Full Name & Age: *Expected Daddy's Full Name & Age: *Home Address: *Contact #'s & Email Address: *Expected Due Date: *Is this your 1st pregnancy: *Are you expecting multiples: If yes to above question, please specify: Twins Triplets Quads Other *Have you been diagnoised as high risk? Explain: *Prenatal care provider contact information: *Birth Location: Hospital Birthing Center Home Other *Do you have a birthing plan? Briefly describe: *What role would you like your partner to play: *Why are you considering a labor Doula: *Describe previous labors? If applicable: *Will this birth be vaginal or c-section: *Describe your current physical health: *Please list all medication you are on: *What coping techniques would you like to use: *What are your greatest concerns during labor: *What will be 3 important elements in your labor: *Imagine your ideal birth ..please describe: *Who will be present during your labor: Please list additonal concerns:
