Patient Name
First Name
Last Name
Date
-
Month
-
Day
Year
PRIVIOUS BIRTH EXPERIENCE
Is this your first pregnancy?
Yes
No
If not, how many pregnancies previously?
How many children do you have?
How many vaginal deliveries?
How many cesarean deliveries?
Was labor induced using Pitocin?
Yes
No
Unknown
Was there any hip or back pain during labor?
Yes
No
Was baby in a suboptimal position during the pushing phase of labor?
Yes
No
Unknown
Did you receive an epidural?
Yes
No
Were there any operative devices used?
Yes
No
Forceps
Vacuum
Any postpartum complications or long term consequences?
Yes
No
If yes:
Any other details you would like to provide?
Do you plan to follow the same plan as your previous delivery?
Yes
No
If not, what would you like to change?
CONCEPTION & EARLY PRAGNANCY
When is your expected or calculated due date?
-
Month
-
Day
Year
How many weeks are you?
Did you have any difficulty conceiving?
Yes
No
If yes, please explain:
Have you used any form of hormonal contraceptives?
Yes
No
If yes, which ones and how long?
Have you experienced morning sickness?
Yes
No
If yes, please explain:
CURRENT HEALTH CONDITION
What type of exercise are you currently performing?
Please tell us about your current diet, and any dietary restrictions:
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 this pregnancy?
Yes
No
If yes, please explain:
Have you had any major emotional stressors during this pregnancy?
Yes
No
If yes, please explain:
YOUR BIRTH PLAN
What are your top 3 goals for this pregnancy?
1
2
3
Do you currently have a birth plan?
Yes
No
If yes, please explain:
Are you taking any pre-natal or birthing classes?
Yes
No
If yes, please explain:
Who is your OBGYN or Midwife?
Will he/she be present for delivery?
Yes
No
Who is your birth provider?
Do you intend to have a birth coach or doula present?
Yes
No
If yes, please explain:
Do you wish to have a medicine free labor and delivery?
Yes
No
Any concerns?
Do you plan or breastfeeding your child?
Yes
No
What would you like to gain from chiropractic care during your pregnancy?
Is there any thing else you'd like to tell us about your pregnancy or birth plan?
Are there any burning questions you want to be sure to ask today?
Submit
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