Eden Birthworkers Community Based Birth and Postpartum Doula Client Forms Personal Information Name___________________________________ DOB__________________________________ Pronouns_______________________________________________________________________ We use anatomical terms for reproductive organs and body parts, please specify if you would like us to use specific terms when discussing your body ____________________________________ ______________________________________________________________________________ Occupation ______________________________Email _________________________________ Phone Number_______________________Emergency Contact ___________________________ Relationship__________________ Phone Number____________________ Home Address _________________________________________________________________ Directions _____________________________________________________________________ ______________________________________________________________________________ Who referred you? __________________________________________________________________ Care Providers Primary Provider _______________________________________________________________ Back Up Provider _______________________________________________________________ Place of Birth _______________________________________Phone______________________ Home Birth Backup Hospital ____________________________Phone_____________________ Have you toured the facilities? ______________ Has a file been opened? ___________________ Childbirth Classes ____________________ With Whom _____________________________ Breastfeeding Classes__________________ With Whom _____________________________ Other Classes __________________________________________________________________ Other Health Care Providers You See _______________________________________________ Previous Pregnancies Date Week Weight Outcome Length of Labour Meds, interventions, complications Eden Birthworkers Community Based Birth and Postpartum Doula Client Forms Medical History: Mark all the apply Yes/No Have you ever breastfed before? Have you ever experienced postpartum depression/psychosis? Do you have any other mental health needs? Anxiety High blood pressure Diabetes Heartburn Fatigue Carpal Tunnel Digestive conditions Haemorrhoids Insomnia Muscle Cramps Shortness of breath Swelling/oedema Other Details/problems/explanation/concerns Eden Birthworkers Community Based Birth and Postpartum Doula Client Forms Others who live in your household __________________________________________________ ______________________________________________________________________________ Plan of care for other children during labour __________________________________________ ______________________________________________________________________________ Plan of care for pets during labor ___________________________________________________ ______________________________________________________________________________ People you will have attend your birth _______________________________________________ ______________________________________________________________________________ Are you wanting photography/video? _______________________________________________ Who will be taking pictures/video? ________________________ How graphic? _____________ Where in your body do you usually feel tension? ______________________________________ How do you manifest tension: ___ difficulty breathing ___ sweating ___ panic ___nausea ___ moaning ___ grinding teeth ___clenching fists ___ racing heart ___ anxiety ___ other_____________ How do you comfort yourself when experiencing stress or pain: ___ distraction ___ movement ___ silence ___turning inward ___ self-medicating behaviours ___ OTC drugs ___ hot/cold packs ___ companionship ___ physical self-soothing other _________________________________________________________________________ What is your plan for coping with the pain of labor? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ How do you feel about medical procedures/intervention in birth? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Eden Birthworkers Community Based Birth and Postpartum Doula Client Forms Anything else I should know to support you? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Are there any cultural/religious choices/preferences that should be taken into consideration? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What is your vision for this birth ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What are your expectations of your doula? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Eden Birthworkers Community Based Birth and Postpartum Doula Client Forms Date Time Notes Eden Birthworkers Community Based Birth and Postpartum Doula Client Forms Date Time Notes Eden Birthworkers Community Based Birth and Postpartum Doula Client Forms Date Time Notes Eden Birthworkers Community Based Birth and Postpartum Doula Client Forms Date Time Notes Eden Birthworkers Community Based Birth and Postpartum Doula Client Forms Date Time Notes Eden Birthworkers Community Based Birth and Postpartum Doula Client Forms Date Time Notes Eden Birthworkers Community Based Birth and Postpartum Doula Client Forms Date Time Notes Eden Birthworkers Community Based Birth and Postpartum Doula Client Forms Date Time Notes Eden Birthworkers Community Based Birth and Postpartum Doula Client Forms Date Time Notes Eden Birthworkers Community Based Birth and Postpartum Doula Client Forms Date Time Notes Eden Birthworkers Community Based Birth and Postpartum Doula Client Forms
