CDP Data Collection Form

Date Created: March 31, 2022

Invoice Form (Credentialed Doulas)

Invoice Date: 09/28/2021

Check All Services Provided:

• Birth

Client Confidentiality Release Form

Signature:

Date signed: 09/18/2021

Date of birth: 12/07/1980

Online Birth Data Survey

Primary doula: Heidi Donahue

Insta-doula birth: Yes

Back-up: No

Racial/ethnic minority: No

Limited/no English: No

Homeless/underhoused: Don't Know

Client is <21: No

Limited/no social support: Yes

Medically high risk: Yes

ACES score: N/A

Due date: 09/24/2021

Primipara (first birth): No

Had client ever had a prior cesarean?No

Had client ever had a prior vaginal birth?Yes

Was this pregnancy multiples (twins, etc.)?No

Was the baby breech?No

Prior to birth was client planning to breastfeed/chestfeed?Yes

Went to Emergency room during pregnancy?Don't Know

Was the baby admitted to the NICU?No

Did the client and baby go home from the hospital at the same time?Yes

After discharge was the baby readmitted to the hospital?No

After discharge was the client readmitted to the hospital?No

After birth, did the baby go to the Emergency Room?No

The last time you saw the client was the baby being breastfed/chestfed?Yes, exclusively (no formula; includes pumped breastmilk given in a bottle)

Did client relinquish her baby after birth?No

On what date was baby born?09/17/2021

Just before labor, client was planning birth at: Hospital

Where was baby born?Corvallis hospital

Planned mode of birth: Vaginal Birth spontaneous onset of labor

Actual mode of birth: Assisted Vaginal Delivery

Was the baby born: 1-3 weeks early

Baby's birthweight: 6 LBS 13 OZ

Entry date: September 28, 2021

Required Documents Checklist

Confidentiality Release Form:

• Completed

CDP Letter of Agreement:

• Completed

Online Birth Data Survey:

• Completed

Invoice:

• Completed

Entry date: April 1, 2022