postpartum client intake form — The Birth Partner

Email

Partner/ Support Person's Name

Estimated Due Date

Emergency Contact

(Name/Relationship/Phone Number)

Care Provider

Birthing Location

Pregnant Person Allergies?

(Food/Medication)

Please list any medical conditions prior to conception that would impact pregnancy, birth or postpartum.

Other:

How much, and how well are you sleeping during this pregnancy?

What number pregnancy is this for you?

Number of previous births:

Please list the number of living children and their ages

Please describe your physical and emotional prenatal and pregnancy experience so far:

Do you plan to take any newborn education classes? Please list date and location.

Other

Are you and/or your partner/support person reading any books on postpartum or newborn care? Please list below.

Do you have a postpartum support plan?

What is your postpartum vision? If things go perfectly according to this vision, describe what this looks feels like for you.

Are you planning to breast or bottle feed?

Please describe any activities you have been going to physically/emotionally prepare for your birth & postpartum (ex. medication, exercise, etc.)

Do you have any persistent concern/fears regarding your birth or postpartum?

What do you think will be your greatest strength for your pregnancy/birth/postpartum experience?

In what ways do you hope a doula's support with be helpful to you? What types of assistance do you imagine will be most useful?

Please share anything else you would like me to know about you or any topics you would like to discuss.

Client Intake Form