Name

First Name

Last Name

Phone

(###)

###

####

Birthday

Due Date

Have you had any recent injuries, suffer from chronic pain, or limited mobility? Please explain (i.e. lower back, knees, ankle fracture etc).

Describe your daily activities:

Sedentary (Spend most of the day sitting: office job or long commute)

Light Activity (Spend a good part of your day on your feet: teacher or cashier)

Active (Spend a good part of the day doing physical activity: server or mail carrier

Very Active (Spend most of the day doing heavy activity: carpentry or warehouse)

What does your movement consist of (i.e. yoga, walking, long distance running, hiking, strength training, group fitness classes)?

Describe your sleep hygiene.

Please share information on your nutrition.

What is your desired outcome for this pregnancy & birth?

What is your ultimate vision for your wellness as a parent?

What are your expectations for a doula?

Where are you delivering?

Please list name of hospital or birthing center, doctor or midwife, or known birthing team names.

Partner first & last name, occupation, schedule, cell phone number.

What other tools, philosophies, resources etc have you pursued or currently practice to prepare for pregnancy, labor, and postpartum?

Select

Please list the best way to contact you.