What do you ask, and why are you asking?

[DoulaCBE]

I'm always in the process of revamping my intake forms and the intake interview I do with each client. So I'm always asking myself, "Why am I asking this question and what will I do with the information?"

Recently I was surfing the net looking for an abbreviated intake form to send to a repeat client so I didn't have to make one myself and I came across other doulas intake forms/interviews and some were 10+ pages long!

So, I figured I'd start a thread that was 2 fold.
What do you ask? What do you do with that information? To get us examining what we're spending our time and efforts on.

And hopefully by sharing our questions we can refine our own forms and either take out what really isn't needed or add in some very important questions that we didn't think to ask.

I'm thinking this is like a peer review type of situation, we post our intake questions and once we've commented on why and what, others can then give any ideas or feedback.

What information is "need to know" vs "nice to know" vs "doesn't really matter if we know."

Anyone want to play?

[amymaew]

here's mine. I don't know what I would change really. I have to think about it.

[DoulaCBE]

Quote:

Originally Posted by amymaew here's mine. I don't know what I would change really. I have to think about it.

Heh, your intake is like mine 3-4 pages, and to the point. I don't ask about routine prenatal testing though. I do ask if they've had any abnormal test results.

[DoulaCBE]

As soon as I can get my little one off the desktop I'll post mine.

[MaryWolfe]

Thanks for asking this question. I was wondering about that too. The forms I got from my workshop for my certification have soo much information that I don't really know why I need to ask it. I'm afraid not to ask while I'm in the process of certifying. After I'm done I'll probably simplify a little.

[TO Doula]

The form I ask people to fill out is only a page long. Many of the questions on Amy's form are things that come up in conversation - I want to talk about them, not just have them fill out a form, I think. Must ponder.

I don't ask occupation - that's one of those "why do I need to know?" questions. I don't ask date of birth - that seems like an unnecessary privacy violation to me. For a while I didn't even ask about a woman's age, but I started doing that when I noticed some OBs were making different recommendations based on age, so now I ask so I can give them a heads-up about what a doctor might say. But for myself it's unnecessary info. I've seen others ask about marital status - again, I don't see any reason I need to know that, either. Also not sure I need to know about medications they're taking - I don't think that's ever been relevant to my work with a client.

I have more phone entries than Amy's - I sometimes have three or four numbers for people these days. I'm thinking of being more specific on that one, too - what I really want is #1: the number they want me to use to call them, and #2 all the numbers they might call me from on labour day, so I can program them into my phone so they show up on call display!

It would be good to have something to remind myself to make sure we cover questions such as who they want there on the day. Once or twice I've been caught by surprise by a mom I didn't realize was to be included. I also like the sections about how she experiences stress in her body - we talk about that kind of stuff, but it would be interesting to see how a woman answers that with a little time and privacy to think about it, rather than just on the spot in conversation.

Thanks for sharing, Amy, and for bringing this up, Angie. Lots to think about.

[DoulaCBE]

Quote:

Originally Posted by Rean The form I ask people to fill out is only a page long. Many of the questions on Amy's form are things that come up in conversation - I want to talk about them, not just have them fill out a form, I think. Must ponder. It would be good to have something to remind myself to make sure we cover questions such as who they want there on the day. Once or twice I've been caught by surprise by a mom I didn't realize was to be included. I also like the sections about how she experiences stress in her body - we talk about that kind of stuff, but it would be interesting to see how a woman answers that with a little time and privacy to think about it, rather than just on the spot in conversation. Thanks for sharing, Amy, and for bringing this up, Angie. Lots to think about.

Rean,
I don't give my clients my Intake Interview to fill out. It's purpose is exactly what you describe above, a reminder of the questions I want to cover during our prenatal. I have a notes section at the end for things that come up.

I sit down with them and start talking and I do the intake "interview style" meaning I know most of the questions and the order so from the outside it seems like we're having a conversation and really getting to know each other, but the form is my "reminder" of what I'd like to make sure and cover.

Make sens?
I also collect ANY number they might call me from so I can program it into my phone - clients have specific ring and text tones.

[1stimestar]

I don't use an intake form at all anymore. I make a few notes on my copy of the last page of my contract such as dr. they are using but for all the other info, such as previous pregnancies etc. I just remember that info.

[embracebirth]

My q's are listed below. It is a form that I fill out for each client. I don't necessarily ask all these questions in this order and with this exact wording, but I do cover them all at some point in the pregnancy.

Name
DOB
Contact Info
EDD
Planned Place for Delivery
Health Care Provider(s)
Support People
Others who may be present/whom you desire to be @ the birth
People who might desire to be at the birth/might show up, who you don't want there.

What do you know about doulas? & Why do you want a doula?

Starts with where they're at, and allows me to build on what they know & want.

Can you tell me about this pregnancy/your baby - Hi’s, Lo’s, how did family & friends react?, Surprises?
How are things going for you right now: Physically? Mentally/Emotionally? Socially?

Gives me a bigger view of their support systems, stressors etc.

How do you picture the birth going?
Any particular concerns or fears?
What sort of things comfort you or help you feel safe?

Helps me assess what sort of things we'll want to spend more time on in prepping for birth etc.

Do you work outside the home? If so, where/what does it involve?

Gives me a heads up on occupational factors which may impact her pregnancy - on her feet all day in retail? high stress corporate with little time for reflection and self? chemical exposures? etc.

Medical conditions/allergies etc?

I make myself familiar with these issues so that I can understand them & any impact they might have on her experience.

Any religious or cultural beliefs I should be aware of?
Have you been pregnant or given birth before?
Do you feel safe in your relationship?/with the people who will be present at your birth?

Very personal questions which I don't usually ask until some trust has been developed - esp. the 2nd two. BUT all 3 can have a major impact on the birth experience and I think it's important to ask.

How do you feel about birth plans?
What are your priorities for labour; birth; pp; newborn?
Can you tell me how you feel about newborn baby care?
Can you tell me how you feel about (breast) feeding?
Anything else.....

typical stuff

[AMotz]

This is mine - I just redid it a few weeks ago.

In addition to the History, if they have given birth before I use the breakdown form.

[doula Michele]

mine is only a few questions long.....
name, age, occupation, due date, Dr, how many pregnancies, any medical problems.
Then I ask them to describe their ideal birth experience.... most say "I don't know," I have not thought about it. OK, good. Because we are going to think about it!

[AngelsMum]

I haven't made up an intake form, but I can see how it might be useful for someone like me who has a terrible memory.

Hey Amy, are you comfortable with your full details being on the intake form you provided? Just thought I'd mention it in case you forgot.

[sunshine]

here's mine. i just started using one this year and i think i'll adopt a few of the questions i see others using. i love this thread btw.......super helpful discussion.

Client Profile and History

This info is confidential. The more I know about you, the better I may serve your needs.

Name:
Age:
Address:
Phone: home: work: cell:
Est. due date:
Birth location:
Care giver:
Baby’s doctor:

How do you feel about your care provider?
(so we can discuss other options if necessary or talk about any possible problems)


Do you drink alcohol?
Use tobacco?
Do you sleep well?
Do you nap?
Any allergies?
Any conditions pertinent to pregnancy, labor and birth?
(eating disorders, sexual abuse, physical abuse, herpes, gestational diabetes, group b strep, back, hip, pelvic injuries or pain, etc)

(give me a heads up in case someone needs to be referred, extra info)



Have you ever had any procedures done to your cervix (liep, cryofreezing, d & c)?

(doctors don't even bring this up sometimes and it can possibly wreak havoc on a first time mother's labor)

History of depression or anxiety?


Major life stresses right now:




Do you feel safe in your home?


Any religious beliefs pertinent to your birth or my doula service?




Are you planning to breastfeed?

Previous birth history:




Specific concerns about this birth?



Who will attend the birth? (other family members, friends?)

(i like to know who and what relationship they have.....if it doesn't sound good then i can remind mama she is in charge of who is in the room and help support her in that)

[DoulaCBE]

Ok, here's mine.
I do all the contact information plus:
Gender of baby
Breast or Bottle
Circumcising - not done in hospital here very often, if so, we talk about needing to make plans. If undecided (disagreeing) offer more resources for their reference.
Baby's name if they're sharing - so I have baby's name and proper spelling for birth story.
Older children/siblings - nice to know so I can refer to them by name in conversation.


Do you have any allergies or illnesses (chronic or otherwise) of which I should be aware?
I'm looking for anything I should be aware of. Food allergy, medicine allergy, latex allergy, allergy to scents, etc.

Have you had any complications with this pregnancy and any restrictions placed on you by your caregiver?
I'm looking for anything that might have happened that could influence the management of her pregnancy and labor that I should be aware of.

Do you have a history of breast surgery? Augmentation or reduction?
Looking for any history that could influence breastfeeding.

Do you have a history of gynecological surgery? Abnormal paps, D&C, any cervical procedures such as biopsy or LEEP?
Looking for any cervical procedures that could have resulted in scar tissue so that if we see an arrest or slow dilation we can ask providers if they feel any scar tissue and then discuss breaking it up.

Who will be attending the birth and what is their role?
This is a chart. I list each person, their first and last names, how they're related or if they're friends, if they tend to be queezy or nervous, if they will be present for labor or birth or both. This helps me know who to expect to be there, how to get them involved, or not, and gives me names to refer to when I write the birth story.

If, during labor, you feel uncomfortable about any of the people above being present, how would you like that handled? Who will be responsible for addressing the situation?
I operate from "what got the baby in gets the baby out" so as we know some women won't 'perform' with a crowd. We talk about this, we talk about how I've seen labors STOP when mom is uncomfortable and we talk about mom having the right to ask people to leave. We then talk about how we'd like to handle that situation and the possibility of using a code word to alert me or her partner that we need to clear the room.

If someone other than those listed above shows up during your labor, how would you like that handled and by whom?
Again, women need to feel safe and have privacy. We have hospitals where visitors can just walk onto the labor unit unannounced. So we make a plan ahead of time.

Describe your ideal birth.
This ones obvious.

Do you have any concerns or fears about this upcoming birth?
This comes from Penny SImkin's identifying triggers perspective. We try to address fear, make a plan for what we can control and I then become generally aware if mom has any triggers.

Are there any areas where you feel you need further education?
I'm a CBE and our 2nd and 3rd prenatal can be tailored to their needs.

Is there anything that you or your partner could say or do in labor that would upset each other?
Physical or mental ticks, bad jokes, etc, nice to know to try and navigate them in labor. One dad told bad jokes so I was able to prevent him from annoying mom when he started by re-directing him into something else.

Do you have any concerns about modesty, visitors or medical students during childbirth?
This opens the "you can refuse to allow medical students, even in a teaching hospital" conversation. It also can tease out triggers that we might not have discovered. Nudity, needing to be covered, etc.

Are there any stressful aspects to your life at the present time?
Anything I should be aware of that I can provide resources or direction on. Or things I should know about that can influence mom's mental state especially around her due date. Things that might delay labor due to stress, etc.

What is your philosophy towards medical intervention including medication? Are there any procedures or interventions that you are extremely opposed to? (Such as induction, episiotomy, use of forceps, IV, internal or external fetal heart monitoring, artificial rupture of membranes.)
Some people would rather have a cesarean than use forceps or vacuum, others are 100% opposed to episiotomy, we create a game plan for those situations. AKA don't sign the consent for vaginal birth with possible episiotomy, instead cross out "possible episotomy" and note "I do not consent" and sign under.

Is there a position that you would prefer to deliver in? (For instance, back-lying, side-lying, semi-sitting, hands and knees, squatting)
A lot of women get stuck in whatever position they're in to start pushing, usually on their backs after a vaginal exam, so if they want to explore other positions I bring that up at the time.

Do you want to view the birth with a mirror?
Make sure it's available.

Do you want to touch your baby as it comes out?
Remind mom to reach down and touch her baby.

Do you want to “catch” your baby or have your partner participate in this?
Help them remember to ask.

Who would you like to cut the cord?
Reminding them in the moment, letting mom know she can cut the cord herself if she'd prefer.

Would you like to see the placenta?
obvious

Would you like to keep the placenta?
make plans prenatally to get it home asap after the birth and to ask for it.

Is there anything special that you plan on doing when your baby arrives? (i.e. birthday cake, song, prayer)
Identifying anything I need to assist with, or ask the staff to allow time for.

Is there anything not covered in the prior sections that you would like to add?
obvious.

[toricaswell]

i've just been writing notes on the last page of the contract.

i ask about their ideal birth experience,
concerns,
ways they like to relive stress, water, exercise, music, dance, massage ect.
plus due date, baby's name, doctor, hospital, gbs status, siblings, other people invited to birth
and as our conversation flows i almost always find out more and make note of these things.