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Please complete this form for every birth attended in person. 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?

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* 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. Which labor support measure were used?

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