Birth Outcome Form

Part I

Client Information:

Client First Name *

Client Last Name *

Client Address*

Client's Gender *

Female

Non-Binary

Transgender F to M

Male

Client Phone Number*

Client Email Address*

Client Occupation

Social Media (Whatsapp, Facebook, etc)

Client's Date of Birth*

Medi-Cal - Y or N?*

Yes

No

Type of Medi-Cal*

HealthNet

LA Care

Straight Med-Cal

Medi-Cal ID Number

Insurance (non-Medi-Cal) Name

Insurance Patient ID Number

Client's Race

Hispanic

Non-Hispanic

Fee for Service - Amount

Date Paid or Due

Doula Information:

Doula's First Name *

Doula's Last Name *

Doula's Address*

Client's EDD*

Doula's Phone Number*

Doula's Email Address*

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Planned Place of Birth*

Birth Center

Home

Hospital

Name of Medical Provider*

Medical Provider Address

Partner's Information:

Client Partner's First Name

Client Partner's Last Name

Client Partner's Age

Client Partner's Gender

Male

Female

Non-Binary

Transgender

Client Medical History

(Link - Confidential Intake Form for emotional/physical abuse or neglect.)

Prior Cesarean(s)

Yes

No

Number of Cesareans

Did client report depression, anxiety in pregnancy?

Yes

No

Did client report depression, anxeity in postpartum?

Yes

No

Did client report lack of respect during labor by care-providers?

Yes

No

Please describe

Did client report lack of respect in postpartum by care provider?

Yes

No

Please describe

Birth Outcome Data

Time early labor began

SROM (time)

AROM (time)

Active Labor Time (from 6 cms)

Length of 2nd stage

Hospital Admission Date

Hospital Admission Time

Doula Present?

Yes

No

Induction

Yes

No

Method of Induction

Gestational Age at Induction

Augmentation

Yes

No

Pain Medication

Yes

No

Pain Medication Type

Epidural

General

Analgesic

Non-Pharmacological Pain Methods Used

Method of Delivery

Vaginal

Cesarean

VBAC

Instrumental Delivery

Yes

No

Type of Instruments

Forceps

Vacuum Extraction

Complications of Delivery

Contact

Staff Pages

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