About
Midwifery Services
Doula Services
Labor Doula Intake Form
Testimonials
Resources & Community Professionals
Contact
About
Midwifery Services
Doula Services
Labor Doula Intake Form
Testimonials
Resources & Community Professionals
Contact
Juliana Taylor, CPM, VT-LM, NHCM (She/Her)
Burlington, VT, 05401
United States
Pregnant Person's Name
*
First Name
Last Name
Pregnant Person's Email
*
Pregnant Person's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Pregnant Person's Phone Number
Partner/Support Person's Name
Partner/Support Person's Email
Partner/Support Person's Phone Number
Estimated Due Date
MM
DD
YYYY
Maternity Care Provider
Practice Name
Birthing Location
Please list any medical conditions prior to conception that would impact pregnancy or birth.
Any Medical Conditions Developed During Pregnancy:
None
Gestational Diabetes
Hypertension
Non-Vertex Fetal Positioning
Group B Strep
Preeclampsia
Insomnia
Anxiety/Depression
Anemia
Pica
Heartburn
Back Pain
UTI/Yeast Infections
Headaches
Other
What number pregnancy is this for you?
Please include spontaneous or therapeutic abortions.
Number of previous births
If applicable, please describe your previous births.
Please describe your emotional and physical experience of pregnancy thus far.
Have you taken a childbirth education, newborn, and/or breastfeeding class? Please list date and location.
If you. have not taken a class but plan to, please include the anticipated provider and date.
Please check any topics you would like to discuss further:
Ways labor can begin
Early labor signs and signals
Belly Mapping & Fetal Positioning
Exercise in pregnancy/postpartum
Post-birth Procedures
Newborn procedures
Feeding your newborn
Postpartum healing
Postpartum support planning
Newborn care
Postpartum nutrition
Perinatal Mood Disorders
Stages of labor
Timing and contractions
Natural comfort strategies/pain management
Breathing Techniques
Positions for Labor
Medicated Labor
Natural Induction
Medical Induction
Common medical procedures in labor
Pain medications/medical interventions in labor
Positions for pushing
Medically Assisted Deliveries
Cesarean Delivery
Perineal health/healing
Other
Describe your current postpartum support plan?
Whatever stage it is in!
Please describe your birth preferences.
Please describe any activities you have been doing to physically/emotionally prepare for your birth. (ex. meditation, exercise, etc.)
What do you think will be your greatest challenge for this pregnancy/birth/postpartum experience?
Do you have any persistent concerns/fears regarding your birth?
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 will be helpful to you? What types of assistance do you imagine will be most useful for you?
How does your partner/support person want to be involved in your birth? I.e. Hands on, share support with doula, or let the doula take the lead.
Please share anything else you would like me to know about you or any topics you would like to discuss.
Thank you!
