PALS Virtual Support Birth Record

Please complete this form for every birth attended virtually. If multiple doulas were present for the labor/birth, each should complete their own birth record form for the client. Thank You!

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* 1. Doula's Name (First and Last):

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* 2. Client's Name (First and Last):

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* 3. Delivery Date:

Date

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* 4. Client's First Pregnancy?

Yes

Unsure

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* 5. Client's Race/Ethnicity:

Black/African American

American Indian or Alaska Native

Asian

Hispanic or Latino

Native Hawaiian or Pacific Islander

White

Other (please specify)

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* 6. Client's Preferred Language:

English

Spanish

Chinese (Mandarin)

Chinese (Cantonese)

Arabic

French

African Languages

Other (please specify)

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* 7. Was labor induced?

Yes

Unsure

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* 8. Was Pain Medication Used?

Yes

Unsure

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* 9. Was delivery done by C-section?

Comments:

PALS Virtual Support Birth Record

Question Title

* 1. Doula's Name (First and Last):

Question Title

* 2. Client's Name (First and Last):

Question Title

* 3. Delivery Date:

Question Title

* 4. Client's First Pregnancy?

Question Title

* 5. Client's Race/Ethnicity:

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* 6. Client's Preferred Language:

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* 7. Was labor induced?

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* 8. Was Pain Medication Used?

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* 9. Was delivery done by C-section?

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* 10. Please describe ways you were able to support the client during and after labor. Please also include your perception of how the client coped.