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Citrus Fruits

Holistic Care Questionnaire

Full Circle Life Coaching Doula Services – Confidential Intake


Please complete the following confidential questions to help us better understand your needs and provide holistic, trauma-informed care during your pregnancy, labor, and postpartum period. Your responses will remain confidential and are shared only with your Doula Provider and relevant care team members as appropriate with your consent.

Have you experienced any pain or discomfort during sexual activity or pelvic exams (past or present)?
Yes
No
Unsure
Do you have any concerns about genital health (e.g., discharge, lesions, itching, discomfort)?
Yes
No
Unsure
Do you currently have any diagnosed sexually transmitted infections (STIs) or diseases (STDs)?
Yes
No
Unsure
Do you have a history of sexual trauma that you believe is relevant to your prenatal, birthing, or postpartum experience?
Yes
No
Unsure
Are there any specific types of touch, physical positioning, or words that make you feel unsafe or uncomfortable?
Yes
No
Unsure
Are there areas of your body you do not want touched, even in a supportive or grounding context (e.g., back, shoulders, feet)?
Yes
No
Unsure
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