Pregnancy Form

Patient First Name

Patient Last Name

Date

PREVIOUS BIRTH EXPERIENCE

Is this your first pregnancy?

Yes No

If not, please tell us about your previous pregnancy and/or birth experience(s) (Duration, Interventions, etc).

Do you plan to follow the same plan as your previous delivery?

Yes No

If no, what would you like to change?

CONCEPTION & EARLY PREGNANCY

When is your expected or calculated due date?

Did you have any difficulty conceiving?

Yes No

If yes, please explain:

Have you ever used any form of hormonal or oral contraceptives?

Yes No

If yes, which ones, and for how long?

When was your last menstrual cycle?

What was your pre-pregnancy weight

Current weight?

Have you experienced morning sickness?

Yes No

If yes, please explain:

CURRENT HEALTH CONDITIONS

What type of exercise(s) are you currently performing?

Please tell us about your current diet, and any dietary restriction.

Have you taken any medications or supplements during your pregnancy?

Yes No

Have you taken any medications or supplements during your pregnancy?

Yes No

If yes please explain:

Have you had any slips, falls, or other physical traumas during the pregnancy?

Yes No

If yes please explain:

Have you had any major emotional stressors during your pregnancy?

Yes No

If yes please explain:

YOUR BIRTH PALN

Your top three goals for this pregnancy:

Have you had any major emotional stressors during your pregnancy?

Yes No

If yes, please explain:

Are you taking pre-natal or birthing classes?

Yes No

If yes, please explain:

Who is your OB/GYN or midwife?

Will they be present for delivery?

Yes No

Who is you birth provider?

Do you intend to have a Douala or birth coach present?

Yes No

If yes, please explain:

Do you wish to have a natural vaginal labor and delivery?

Yes No

If not, what concerns do you have?

YOUR POST-BIRTH PLAN

Do you plan on breastfeeding your child?

Yes No

What do you intend to do for vaccines?

Is there anything else you'd like to tell us about your pregnancy or birth plan?

What would you like to gain from chiropractic care during you pregnancy?

Are there any burning question you want to be sure to ask today?

PATIENT REVIEW OF SYSTEM

THE NERVOUS SYSTEM CONTROLS AND COORDINATES ALL ORGANS AND STRUCTURE OF THE HUMAN BODY

Please check corresponding for each symptom or conditions you have experienced -- including both past and present.

REGION : Cervical

Function

Autonomic Nervous System
ENT System
Vision, Balance & Coordination
Speech
Immune System
Digestive System
Nerve Supply to Shoulder, Arms, Hands
Sympathetic Nucleus
Metabolism

SYMPTOMS

Colic & Excessive Crying

Past Present

Ear & Sinus Infections

Past Present

Allergies & Congestion

Past Present

Immune Deficiency

Past Present

Headaches & Migraines

Past Present

Vertigo & Dizziness

Past Present

Sore Throat &Strep

Past Present

Swollen Tonsils & Adenoids

Past Present

Vision & Hearing Issues

Past Present

Low Energy & Fatigue

Past Present

Difficulty Sleeping

Past Present

Pain, Numbness & Tingling in Arms to Hands

Past Present

Epilepsy & Seizures

Past Present

Sensory & Spectrum

Past Present

ADD / ADHD

Past Present

Focus & Memory Issues

Past Present

Anxiety & Stress

Past Present

Balance & Coordination

Past Present

Speech Issues

Past Present

TMJ / Jaw Pain

Past Present

Stiff Neck & Shoulder

Past Present

Depression

Past Present

High Blood Pressure

Past Present

Poor Metabolism & Weight Control

Past Present

REGIONS : Upper Thoracic

FUNCTIONS

Upper G.I.
Respiratory System
Cardiac Function

SYMPTOMS

Reflux / GERD

Past Present

Asthma

Past Present

Chronic Colds & Cough

Past Present

Bronchitis Pneumonia

Past Present

Functional Heart Conditions

Past Present

REGIONS : Mid Thoracic

FUNCTIONS

Major Digestive Center
Detox & Immunity

SYMPTOMS

Gallbladder Pain & Issue

Past Present

Jaundice

Past Present

Fever

Past Present

Indigestion & Heartburn

Past Present

Stomach Pain & Ulcers

Past Present

Blood Sugar Problem

Past Present

REGIONS : Lower Thoracic

FUNCTIONS

Stress Response
Filtration & Elimination
Gut & Digestion
Hormonal Control

SYMPTOMS

Behavior Issues

Past Present

Hyperactivity

Past Present

Chronic Fatigue

Past Present

Chronic Stress

Past Present

Allergies & Eczema

Past Present

Skin Conditions & Rash

Past Present

Kidney Problems

Past Present

Gas Pain & Bloating

Past Present

REGIONS : Lumbar, Sacrum & Pelvis

FUNCTIONS

Lower G.I. (Absorption & Motility)
Gut-Immune System
Major Hormonal Control

SYMPTOMS

Constipation

Past Present

Chronics, Colitis & IBS

Past Present

Diarrhea

Past Present

Bed-wetting

Past Present

Bladder & Urination Issue

Past Present

Cramps & Menstrual Issues

Past Present

Cysts & Endometriosis

Past Present

Infertility

Past Present

Impotency

Past Present

Hemorrhoids

Past Present

Sciatica & Radiating Pain

Past Present

Lumbopelvic / SI Joint Pain

Past Present

Hamstring Tightness

Past Present

Disc Degeneration

Past Present

Leg Weakness & Cramps

Past Present

Poor Circulation & Cold Feet

Past Present

Knee, Ankle & Foot Pain

Past Present

Week Ankle & Arches

Past Present

Lower Back Pain

Past Present

Gluten & Casein Intolerance

Past Present

Patient First Name

Patient Last Name

Signature

Date

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