Mark which applies:       Mother        Doctor         Midwife         Nurse        

Mother's Name: 

Doula's Name: 

Care Provider's Name: 

Baby's Date of Birth: 

Birth Location: 

Use this scale to Answer the Questions Below:
Negative Impact       No Noticeable Impact      Positive Impact
        1                2                3                4                5        

1. Was the presence of the doula helpful to the mother in handling the physical aspects of labor?

       1        2        3        4        5       

2. Was the presence of the doula helpful to the mother in handling the emotional aspects of labor?

       1        2        3        4        5       

3. How was the presence of the doula for the entire labor team?

       1        2        3        4        5       

4. Overall, how useful was the presence of this doula?

       1        2        3        4        5       

Please Explain: 

Additional Comments: