Postpartum Client Questionnaire

We are excited to go on this journey with you. Over time we will get to know each other better, and by filling out this questionnaire, we can hone in on some important details that will help us serve you in a meaningful and effective way.

Please take the time to fill out this questionnaire at your earliest convenience. It can require some reflection and research, so we recommend jumping into this sooner rather than later.

Birthing Person's Info

Name

First Name

Last Name

Phone

(###)

###

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Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Age

Partner/Spouse Contact Info

Name

First Name

Last Name

Phone

(###)

###

####

Children

How many children do you have

Name(s)/Age(s)

Please list the names and ages of your children:

Pregnancy Details

Estimated Due Date/Baby's Birthday

YYYY

Care Provider's Name

Care Provider's Practice Name

Care Provider's Phone Number

(###)

###

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Medical History

Current Medical Information

Please provide any current medical information regarding this pregnancy that may be important to know for your postpartum support.

Prior Medical History

Please provide details of any relevant prior medical history below:

Current Supplements and/or Medications

Please list any supplements (including vitamins) and medications (including over the counter) that you are currently taking below:

Smoke or Vaping

Does anyone in the household smoke or vape?

Previous Births

Please share about your previous birth(s) below:

Previous Miscarriage

If yes, please provide details below:

Trauma

Have you experienced sexual abuse or trauma?

Additional Info

If yes, please use the area below to provide any information you would like to share and that you feel is important for us to know in order to best assist and serve you.

Mental Health

Is there anything regarding your mental health history that you feel we should be aware of?

Desires, Hopes, Concerns, Fears, and Questions

Concerns For Postpartum Period

Do you have any fears or concerns about the postpartum period including physical and emotional recovery? If so, please share your thoughts and/or questions below:

Postpartum Mood Disorders

Do you have any fears or concerns about possible postpartum mood disorders? If so, please share your thoughts and/or questions below:

Questions

Do you have any specific questions about the postpartum period?

Postpartum Support Team

Support Team

Where does most of your support come from? Who do you plan to have around and available to help with support during the postpartum period? This will include anyone who will be providing support in your home or helping with items outside of the home. Additionally, you can include anyone you do not wish to be present during this time.

Postpartum Doula Support

How do you picture your postpartum doula supporting you?

Partner Support

How do you picture your partner supporting you during the postpartum period? What are the strengths that you know will be beneficial to you during this time? What are the areas you are concerned about?

Getting to know you more

Education

Do you plan to take any classes prior to your birth? If so, please provide details. For example: Breastfeeding, Newborn Care, Baby Wearing, etc.

Cultural/Spiritual/Religious Preferences

Do you have any cultural, spiritual, or religious preferences you'd like us to be aware of?

Parents and In-Laws

How is your relationship with your parents? If you are married, how is your relationship with your in-laws?

Anxiety

Do you struggle with anxiety? If so, what does anxiety look like for you? Do you know your triggers and early signs?

Coping when unwell

What makes you feel better when you are sick, stressed, anxious, tense, or in pain? How do you comfort yourself? For example: distractions, rest, warm soup, talking it out, movement, silence, turning inward, laughter, self-medicating, OTC drugs, hot/cold therapies, sleeping, companionship, food, meditation, essential oils, etc. Include all that apply and feel free to add your own.

Your Time Off

Do you have time off work? If so, how long?

Partner's Time Off

Does your partner have time off work? If so, how long?

Dietary

Does your household have any dietary limitations or allergies?

Pets

Do you have any pets? If so, please let us know how many and what types and any important information we may need to know.

For Your Baby

Infant Feeding

How do you plan to feed your baby?

Diapering

Which method of diapering do you plan to use?

Parenting Techniques

Are there any parenting techniques you plan to use or have any questions about?

Baby

What is most important to you in regards to caring for your baby?

Questions

Do you have any specific questions about newborn care?

For Your Partner/Spouse

Worries and Concerns

(Partner) Do you have any worries or concerns about the postpartum period?

Expectations for Doula

(Partner) What are your expectations from your postpartum doula?

Comforting the Birthing Person

(Partner) How do you comfort your partner when they are stressed, sick, injured, or anxious? Can you see how these methods may benefit your partner during the postpartum period?

Partner Educational Materials

(Partner) Would you like additional materials (books, classes, videos, podcasts) specifically geared towards partners?

Closing

Final Thoughts

Use this area to ask any additional questions or share any additional information you feel we should know that can help us provide meaningful and effective postpartum support for you.

Responses

Would you like a copy of your responses?