Forms | K + E Support Co.

Name *

Email address *

Partner's Name *

Doctor / Midwife / Practice Name *

Intended Hospital for Delivery *

Address *

Cell Phone *

Estimated Due Date *

Baby's Gender *

Boy
Girl
Unknown

Baby's name (if known)

Planned Method of Feeding *

Breastfeeding
Formula Feeding
Both
Not sure but would like more information

Please state your general health

Do you have any allergies we should be aware of?

Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you, and any medications you are currently taking.

Have you given birth before? *

No
Yes, vaginally only
Yes, cesarean only
Yes, vaginally and cesarean

Who do you planned to support you in the delivery room? (Choose all that apply) *

Partner
Doula
Mother / Mother-in-law
Sister
Friend
Other

Do you have a birth vision planned? *

Yes, it is a final copy
Yes, but it is a draft and would like some help
No, I would like some help creating one
No, I have no interest in one

How do you feel about interventions in labor/delivery? *

What type of pain management are you planning to have? *

Comfort Measures
IV Medication
Epidural
Other

What type of comfort measures would you like to use in labor? (Check all that apply)

Distractions
Breathing Patterns
Massage
Birth Ball/Peanut Ball
Walking, Dancing, Swaying
Water (Tub or Shower)
Hot / Cold Therapy
Visualization / Imagery
Focal Points
Aromatherapy
Music

What is your vision for this birth? *

What are your expectations for your doula? *

Any other questions or concerns?

Which doula are you hiring? *

Katlynn
Breona
Katherine
Brooke
Cameron
Jessica

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