These questions may help you communicate with your doula, allowing her to support you in the most effective way possible. They may also allow you to think about yourself and your needs more clearly. If any of these questions are inapplicable or uncomfortable for you, please feel free to leave them blank. All personal information you provide to Month 10 will be held in confidence.

Name:

Spouse or Partner:

Address:

Phone:

Cell Phone:

Spouse work phone:

E-mail:

Preferred method of contact:

Names/ages of other children:

Name of Midwife/OB/Caregiver:

Where do you plan to give birth?

Is this your first pregnancy/birth?

Do you plan to receive medication during labor?

Do you plan a vaginal or operative delivery?

Have you taken a childbirth or breastfeeding class?

Will you circumcise a male baby? If so, when?

Any cultural/religious or family traditions to be observed:

How would you describe your pregnancy?


Who will be helping you at home after the birth? For how long?


Have you experienced any major changes in the past 12 months (moved, changed jobs, had a family death, etc.)?

Have you read any books or magazines on parenting/baby care? Which ones do you like/dislike?

What aspect of parenting/baby care concerns you the most?

Have you cared for an infant before?

Do you plan to breastfeed, formula feed, pump and bottle feed, or a combination?

Where will your baby sleep for the first two months?

Are you currently employed? Do you plan to return to work after the baby is born? What are your plans for feeding/childcare at that time?

Do you have a history of depression? Are you currently on anti-depressant medication?

What would you like from your doula? 1=very important; 2=less important; 3=maybe

____Caring for baby/babies while resting, bathing, etc.
____Running errands
____Baby care techniques and education
____Breastfeeding support
____ Meal preparation
____Emotional support
____Help with organizing/tidying household/laundry
____Helping older siblings to adjust
____Other _____________________________

Are there food allergies or food preferences that we should know about when preparing meals?

Do you have favorite meals that you would like us to prepare?

What is your basic household schedule? (Meal times, naptime, bedtime for children etc.)

Who else is likely to be working in your home at the same time that we will be helping you?

Is there anything else that you would like to tell us about yourself or your family?