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Nurtured by Maya- personalized support during your postpartum journey
Client Information
First name
Last name
Email
Phone
Preferred Contact Method
Text
Phone Call
Email
Birthday
Month
Day
Year
Address
Partner/Spouse involved in pregnancy?
Yes
No
Other
Name of partner/support person
Email
Phone
Emergency Contact
Name
Relationship to Client
Phone
Email
Preferred Contact Method
Text
Phone Call
Email
Authorized to make medical decisions in case of emergency
Yes
No
Health and Medical Information
Primary Care Provider
Obstetrician/Midwife
Clinic/Hospital Name
Clinic/Hospital Contact Phone #
Known Allergies
Current Medications/ Supplements
Medical Conditions (check all that apply)
High Blood Pressure
Preeclampsia
Gestational Diabetes
Anemia
Other (please specify)
Are you working with any other healthcare professionals (e.g, chiropractor, therapist)?
Yes
No
If yes, please specify:
Do you have any physical limitations, disabilities, or special accommodations needed?
Yes
No
If yes, please describe:
Any additional information you would like me to know?
Do you have a history of anxiety, depression, or other mental health conditions?
Yes
No
How are you currently feeling-physically and emotionally- about this postpartum period?
Do you have a support system (family, friends, professionals) in place?
Birth Information
Place of Birth (Hospital/center/Home)
Was this your first pregnancy?
Yes
No
Type of Birth ( Vaginal/C-Section/Assisted/Other)
Are there any medical procedures you or your baby are still recovering from (e.g, stitches, catheter, NICU stay)?
Is there any additional information from your birth experience you would like to share?
Is your baby currently experiencing any health concerns or feeding challenges?
Were you discharged with any specific postpartum instructions or medications
Family and Household
Name and ages of other children:
Do any children have allergies or special needs? If so,please explain:
Pets in the home (type and temperament):
Languages spoken at home
Cultural or religious practices you'd like the doula to be aware of:
Do you have other caregivers regularly in the home (e.g, grandparents, nannies, etc)? If yes, please specify:
What are your families typical routines (e.g, wake-ups, meals, bedtimes)?
Does anyone in the family have an allergy or intolerance?
Yes
No
If yes, please detail
Do you follow any specific dietary preferences or restrictions (vegetarian, gluten-free, Halal)? If yes, please detail
How long will your maternity leave be?
are there areas of the home you prefer the doula not enter or use (e.g, certain rooms)
Yes
No
If yes, where?
Postpartum Goals and Expectations
What are your top priorities for postpartum support?
Newborn Care
Bottle Feeding Support
Breastfeeding support
Meal Prep
Light Housework
Sibling care/support
Emotional Support
Other
Do you have any concerns or fears about the postpartum period?
What would make you feel most supported at this time?
What does an ideal postpartum day look like to you?
Are there any specific boundaries or preferences you'd like the doula to respect? If yes, please specify:
Availability and Logistics
Preferred start date for postpartum support:
Preferred time(s) of day (morning, afternoon,evening, overnight)
Number of hours/days per week desired:
Are there specific days or times to avoid?
Parking or entry instructions for the doula
Communication and Boundaries
Preferred Contact Method
Phone
Text
Email
Are there any topics that are off-limits or sensitive to you?
How do you prefer to hear feedback or suggestions?
What makes you feel most respected and comfortable when receiving help?
Newborn Care Preferences
Feeding Plan (Breast/ Bottle/ Combo? Still Deciding):
Are you currently working with a lactation consultant or feeding specialist?
Yes
No
Do you plan to use pacifiers or have a sleep plan in mind?
Do you have preferred baby care products or method (e.g, cloth diapers, baby-led sleep, elimination communication, etc)?
Do you have any specific parenting philosophies or practices I should be aware of?
Anything else at all you want your doula to know?
Date
Month
Day
Year
Signature
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