PREGNANCY INTAKE FORM | ForeverYoung Chiro

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Pregnancy Intake Form

Thank you for choosing ForeverYoung!

If you have booked an initial exam with us, please take the time to fill out this form the best you can prior to your appointment day. This helps to keep the clinic running smoothly and your appointment on time!

How did you hear about us?

Patient First Name

Gender

Phone

Patient Last Name

Birth Date

Email

Street Address

City

Postal / Zip code

Region/State/Province

Country

Name of Spouse/Partner

Occupation

Name of Children + Ages

Employer

Band Member ID (where applicable)

HEALTH CARE PROVIDERS

Family Doctor

Midwife

Doula

OB/GYN

Naturopath

Massage Therapist

Acupuncturist

Other Care Providers

Please any health conditions you have been treated for in the last year

Have you had previous Chiropractic Care?

If yes, have you been adjusted?

Reason for Visit

PATIENT SYMPTOMS

Describe your chief complaint

When did it start?

Complaint is getting

What may have caused it?

Complaint started

Duration of symptoms

Is the complaint worse at a certain time of day?

Has the complaint affected your daily activities?

Has the complaint affected your ability to sleep?

Has the complaint affected your appetite?

Has this happened before?

Have you had to miss work?

Does the weather affect your complaint?

What makes your complaint feel worse?

If yes, what time?

If yes, how?

If yes, how?

If yes, how?

If yes, when?

If yes, when was your last day of work?

If yes, how?

What makes your complaint feel better?

How does your complaint interfere with the following areas of your life?

Family:

Work/School:

Sports/Hobbies:

MEDICAL HISTORY

Have you been involved in an Auto/ATV accident?

Date of last accident?

If yes, how many accidents?

Known trauma from accident?

Do you experience frequent illnesses/colds/flus?

Any hospitalizations or surgeries?

Are you on any type of medication?

Do you have any environmental allergies?

Do you have any food allergies?

Do you smoke?

Do you drink soda pop?

Do you drink alcohol?

If yes, what?

Please list all -

If yes, what?

If yes, what?

If yes, what do you smoke and how much per week?

If yes, how much per week?

If yes, how many drinks per week?

Family History of (check all that apply)

Heart Disease

Cancer

Diabetes

Arthritis

Other

YOUR PREGNANCY

How many weeks pregnant are you?

Plan to birth at

Have there been any concerns with any of your check-ups so far?

What is your due date?

Are you using a

If yes, please explain

PREGNANCY HISTORY

Have you had any previous pregnancies?

Child/Childrens' birth was at

If yes, how many?

Did you use a

Your child/childrens' birth was

If vaginal with interventions (check all that apply)

Induction

Medication

Epidural

Episiotomy

Vacuum extraction

Forceps

Manual extraction

Other

Please list reasons for intervention/complications

Are you currently breastfeeding or pumping for bottle feeding?

WOMEN'S HEALTH

Do you usually have a regular menstrual period?

Average length of cycle?

Do you usually have painful periods?

Any pelvic conditions (PCOS, Endometriosis, Fibroids, Hysterectomy)?

If yes, what?

QUALITY OF LIFE

Current level of negative stress?

Current energy level?

How well do you cope with stress?

Current nutritional intake?

Is there any other information you would like us to know?

What do yo expect from your chiropractic care?

FAMILY CONCERNS

Does your spouse/partner have any health concerns?

Do any of your children have any health concerns?

Thanks for submitting! We have received it.

613-507-5007

510 Canatara Court

Kingston, ON K7M 0G3

613-966-5855

Shannonville, ON K0K 3A0

©2022, ForeverYoung Chiropractic.

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