Birth Outcome Form

BIRTH OUTCOME FORM – HAPPY MAMA HEALTHY BABY ALLIANCE COMMUNITY DOULA PROGRAM

This information is confidential and will only be used by HMHBA to track outcomes and quality assurance. Doulas should complete the form at intake. (* = required)

The forms for prenatal and postpartum visits are here.

Part I

Birth Outcome

Venice Family Clinic has a unique client ID. It’s their patient record number. *** United Healcare format is the following: UHC in front of the woman's initials. Then first initial, Last initial, woman’s birthday, and year of service. *** For those not receiving services under grants the format is the following: first initial, last initial, woman’s birthday, and year of service. Example: MP941991-2023

Doula Information:

Partner's Information:

Client Medical History

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

Birth Outcome Data

 

Part II

Postpartum Information

Baby's Information

Breastfeeding

Client Problems