Pregnancy Intake Name: * First Name Last Name Date of Birth: * MM DD YYYY Phone: * (###) ### #### What cell service provider do you use? * Email: * Address: * Marital Status * Single Married Widowed Divorced How did you hear about us? Screening/Event Online Search Social Media Referral Other Weeks Gestation: * Estimated Due Date: * MM DD YYYY Is this your first pregnancy? * Yes No If no, how many pregnancies have you had? Number of Vaginal Deliveries: * Number of Cesarean Sections: * Name of your Physician/Midwife/OBGYN: Planned location for birth: * Hospital Birth Center Home Other Have you had any complications with this pregnancy? * Yes No If yes, please explain: Have you received chiropractic care with other pregnancies? * Yes No Reason for seeking care: * When did your concerns begin? * How did your symptoms start? * Sudden Gradual Are your symptoms constant or intermittent? * Constant Intermittent Please check any symptoms you are CURRENTLY experiencing or have experienced in the PAST. Dizziness Back Pain Hip Pain Sciatica Neck Pain Water Retention Diabetes High Blood Pressure Headaches Asthma Digestion Issues Sinus Issues Have you experienced any morning sickness? * Yes No If yes, frequency: Did you have difficulty conceiving? * Yes No If yes, explain: Do you currently have a birth plan? * Yes No If yes, please describe your wishes: What would you like to gain from chiropractic care during pregnancy? * Do you wish to have a medicine-free / intervention-free delivery if possible? * Yes No Please list any concerns that you have or any other additional information you would like to share about your birth plan or pregnancy: Would you like a complimentary nervous system evaluation for your baby following delivery? * YES - Absolutely! Unsure - I'd like to learn more NO - We are not interested at this time More General Health Questions Please list any other health concerns that have prompted your first visit: * Rate the Severity: * (0=no pain, 10=unbearable pain) When did this problem begin? * Have you had this condition in the past? * Yes No Did this problem begin with an injury? * Yes No Is this problem constant or intermittent? Constant Intermittent Please check any current or previous health concerns: * ADD/ADHD Allergies Anxiety Arm Pain Asthma Back Pain - Upper Back Pain - Mid Back Pain - Lower Chest Pain Chronic Fatigue Constipation Depression Disc Problems Dizziness Ear Infections Fibromyalgia Food Sensitivities Gastric Reflux Headaches Heart Disorder Hip Pain Infertility Irritable Bowel Knee Pain Leg Pain Lupus Menstrual Issues Migraines Neck Pain Nervousness Numbness in Arms/Hands Numbness in Legs/Feet Sciatica Shoulder Pain Sinus Issues Skin Issues Sleep Issues Stomach Disorders Throat Issues Thyroid Problems TMJ Ulcers Vertigo Arthritis Sexual Dysfunction Blood Pressure H/L Other Have you seen other doctors for these concerns? * Yes No If so, what type? Chiropractor Medical Doctor Other Location of Pain (AREA OF MAIN CONCERN): * How would you rate your pain RIGHT NOW? * (0 = no pain, 10 = unbearable pain) What is your TYPICAL or AVERAGE pain? * (0 = no pain, 10 = unbearable pain) What is your pain level AT ITS BEST? * How close to "0" does your pain get at its best? What is your pain level AT ITS WORST? * How close to "10" does your pain get at its worst? Have you ever been involved in an auto accident? * Yes No If yes, when? Please describe any other traumas you have undergone: * Please check any condition you have currently, or have had in the past: Stroke Seizures Cancer Spinal Bone Fracture Heart Disease Scoliosis Spinal Surgery Diabetes Type 1/2 Please list all hospitalizations and surgical operations you have undergone within the corresponding year: * Please list all medications you are currently taking: * How would a change in your health positively impact your life? *Please be specific with the goals you are hoping to achieve through your care at our office. (i.e. 'I could work out again, I could play with my grandchildren, etc.') * Please identify any daily activities that are impacted by your health concerns: * Lifting/Carrying Objects Sit to stand Climbing stairs Driving Extended Computer Use Exercise Household Chores Lifting Children Dressing Sexual Activity Sleep Sitting Standing Work/Job Tasks Walking Washing/Bathing Yardwork Concentration (reading) Other We can’t wait to meet you!
