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Doula Client Questionnaire
A series of questions created to help me create a customized package for you
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Email
*
Your email
Age
Your answer
Height and Weight
Your answer
How many weeks pregnant are you?
Your answer
Is this your first pregnancy?
Your answer
Are you predisposed for diabetes?
Your answer
Do you have any medical conditions?
Your answer
What foods do you like to eat?
Your answer
What foods do you hate?
Your answer
Salty or Sweet?
Salty
Sweet
Both
Clear selection
Do you like spicy foods?
Yes
No
Sometimes
Clear selection
Do/ Did you smoke?
Yes
No
Occasionally
Clear selection
Do/ Did you drink?
Yes
No
Occasionally
Clear selection
Do you exercise? If so, what kind and how often?
Your answer
What are your pregnancy goals?
Your answer
do you plan to take prenantal classes?
Yes
No
Maybe
Clear selection
Do you have any pregnancy concerns?
Your answer
Are you taking your prenatals daily?
Inconsistently
No
Yes
Clear selection
Are you taking any other vitamins?
Your answer
What kind of soaps do you use on your skin?
Your answer
What kinds of lotions/ oils do you use on your skin?
Your answer
If healthy mom and baby are already taken care of, what are you 3 top priorities for this birth?
Your answer
Where is your ideal place to give birth?
Your answer
What clinical personnel will be taking care of your medical needs?
Your answer
Who would you like to be at your birth with you?
Your answer
How do you feel about being induced if you are over your due date?
Your answer
Are you comfortable with IVs?
Yes
No
Maybe
Clear selection
What methods would you like to use to speed up labour (medical and natural)?
Your answer
What methods would you like to use for pain relief during labour?
Your answer
Do you have any concerns about the postpartum period?
Your answer
What are your postpartum goals?
Your answer
What family support do you have? How long is your partner taking off work?
Your answer
How are you planning to feed your baby? Do you have any concerns surrounding this?
Your answer
Do you plan to co-sleep with your baby or will they be in a crib?
Your answer
Do you know how to bathe a baby?
Yes
No
Maybe
Clear selection
Have you done any reading or classes to prepare for the postpartum period?
Yes
No
Maybe
Clear selection
Is there anything you feel your Doula should know?
Your answer
What are you hoping to get out of having a Doula?
Your answer
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