Birth Doula Questionnaire Birth Doula Questionnaire Name: Spouse or Partner: Address: City State/Province Zip/Postal Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Country Phone: Cell Phone: Email Address: Name of Care Provider: Where do you plan to give birth? Due Date Your Pregnancy How is your pregnancy going? Are you attending childbirth education classes? Yes No Where? Are there any pregnancy complications I should know about? Are there any other medical or physiological needs I should know about? Getting to Know You What kind of work do you do? What does your partner do? What do you do for fun? How do you spend some typical time away from work? What are the most stressful aspects of your life at present? What do you do to counteract this stress? Do you have any relaxation routines? Who do you turn to for support? How will these people help you add a new baby to your family? Your Upcoming Birth Who do you want to be present? What expectations do you have of a doula? What coping techniques do you plan on using during labor and birth? Imagine your ideal birth. What makes it ideal? Knowing that birth is sometimes less than ideal, what things in your ideal birth scenario are the most important to each of you? What are your greatest fears about this birth? In the event of an unanticipated cesarean birth, what aspects of the birth experience would be the most important to you? Your Newborn In ideal circumstances, how would you like to welcome your child? What is most important to you in the 30 minutes after birth? Previous Experiences Have you had any childbearing losses? Have you had any other life traumas that you think might influence your birth experience? Have you had a previous birth experience? If so please give a brief overview. When/how did labor begin? What was the best thing about this experience? What elements would you like to do differently this time?