Nurturing Women Through Their Sacred Birth Experience (Providing Birth Doula Services for the Michiana Area)
Estimated Due Date
Estimated Due Date
Chosen birth location for this birth
Goshen Birth Center
St. Joseph Regional
Lakeland, St. Joseph MI
Birth Provider (Name of practice and/or OB/Midwife)
Have you been happy with your current care?
Do you feel confident in your understanding of your provider's birth philosophy, birth statistics and routine practices?
Have taken a tour of your birth location?
Planning on it
Have you or are you planning on taking Childbirth Classes?
Other providers you see (Chiro, Acupuncture, Homeopath, Massage therapist, yoga)
General Health, pre-pregnancy and now (including anxiety, depression)?
Allergies, sensitivities, diet restrictions
Medications and Vitamins currently taking
Exercise type and frequency?
Do you smoke?
History of personal trauma (While this is an incredibly private thing to share it has potential to affect your labor and birth experience. Knowing this is a part of your story helps me to help you prepare for this experience thoroughly, but only if you feel comfortable sharing with me)
Previous Pregnancies and Births
# of previous pregnancies
Previous pregnancy complications/discomforts and treatment sought:
Please list your previous births, week of gestation at birth, gender, name, weight, and brief labor details (labor length, interventions used, complications), emotional experience for you:
Have you breastfed before? Problems?
Have you had postpartum ocd/depression previously?
General feelings about this pregnancy (Fears/Concerns?)
Current pregnancy discomforts or complications and treatment sought:
Check any that apply
Lack of sleep
Round ligament pain
Pain (nerve, back, tailbone etc)
Results of Blood Glucose Levels?
What is your vision for this birth?
Who will be present during your birth?
What are your expectations of your doula?
Where in your body do you usually feel and hold tension?
How do you manifest tension physically?
Repetitive behavior (picking nails, cracking fingers etc)
How do you comfort yourself when you experience stress or pain?
Self-medicating behavior (Food, alcohol etc)
What is your plan for coping with labor?
How do you feel about medical procedures/interventions during your labor and birth?
How are you preparing mentally for this birth?
How are you preparing physically for this birth?
How are you preparing emotionally for this birth?
Is there anything else that you would like me to know regarding your hopes, fears and vision for your birth?