APPENDIX G
Doula Questionnaire
This questionnaire is designed to create a dialogue and help foster the relationship between the doula and her clients—the mom and her partner. Use this questionnaire to understand more about your own needs, and then give the answers to your doula to create a dialogue about your needs, wants, and history. This will only strengthen your relationship and enhance the support you will receive from your doula. Some of these questions are basic formalities but it’s always helpful to answer all the questions here. Willow has been in situations where some of this information was unknown, and in retrospect, knowing it would have been very valuable.
Expectant parents’ names:
Professions/daily work routines:
Address:
Phone numbers (home and cell and work if applicable):
Emergency contact:
Other people (children, in-laws, etc.) who live in the house (names/nicknames/ages):
If the children have a different mom or dad, please give names, where they live:
Do you have pets?
If yes, name/type/age/details that would be helpful for a doula to know:
Current prenatal care:
Estimated due date:
Baby’s gender (if known):
Mother’s date of birth:
Father’s date of birth:
Please describe mother’s general health:
Describe your prior pregnancies:
Have you ever been hospitalized? If so, when and what for? What was your experience?
Please describe any special dietary concerns mom and dad have or prefer:
Please share an example of favorite “quick” meals, takeout, or snacks of all people/children in the house:
How do you feel about being pregnant? What has felt most exciting? What is different from any previous pregnancy if this isn’t your first?
What is your vision for your birth?
What childbirth education have you done or plan on doing for this birth?
What are five things you would like to experience during labor/birth?
What would you especially like to avoid experiencing during birth?
What are your expectations of our working together? What role do you see your doula playing in your labor and birth?
Are there things you want your doula to avoid doing (phrases you don’t respond to well, places on your body you don’t like to be touched, coaching styles you don’t like, etc.)?
Please list phrases you do respond to well, if known, places you relax when massaged, etc.:
Where in your body do you commonly feel tension?
What type of music relaxes you and takes you to “another place”?
Do you or your partner have any cultural, religious, or spiritual practices or beliefs?
What helps you feel grounded and connected as an individual and as a couple?
List an experience when you felt completely supported by your partner and what he was doing to make you experience this love and support.
When you are sick what makes you feel taken care of, or how do you like to be treated?
What are some activities or practices that help you “reset” when you are exhausted, frustrated, or “hitting a wall”?
What makes you laugh? What type of humor (an example) do you and your spouse enjoy?
Would you like your doula to take photos during your labor and birth? Would you prefer PG photos or would you like to capture the actual birth? What type of camera do you have or would you like to use?
What activities does your child or children really enjoy?
What activities relax your child and help him or her calm down?
What phrases or words does your child respond to best when you are trying to calm or relax him or her?