Confidential Patient Health Profile For The Pregnant Patient Form Page 3
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1
2
3LIFESTYLE HABITS
Do you smoke:
Yes
No
How much? ______________________________________________________
Alcohol Consumption?
Yes
No How many drinks per week? ____________________________________
Are you a coffee drinker?
Yes
No How many cups a day? _____________________________________
Are you a soda drinker?
Yes
No How many cans a day? ______________________________________
How many glasses of water do you drink per day?
0-4
4-8
8-12
12+
Do you sleep well? Rate your sleep from 1 – 10 _________ (10 being the best sleep possible)
How many hours on average do you get in a night?
4-6
6-8
8-10
12+
How do you sleep?
Stomach
Side
Back How old is your current bed? ____________________
Do you eat a healthy diet?
Yes
No
Have you ever been to a chiropractor before?
Yes
No
List any prescription drugs, over the counter medications, vitamins, and natural supplements you are
taking: ____________________________________________________________________________________________
___________________________________________________________________________________________________
Medical Doctor’s Name/Location __________________________________________________________________
When was your last visit? ______________Reason? ____________________________________________________
Have you consulted other healthcare providers for this condition? (RMT’s, Physio, Accupuncture, MD,
ND etc): ___________________________________________________________________________________________
___________________________________________________________________________________________________
Please draw the location of your pain or discomfort on the images below. Use the symbols to represent
the type(s) of pain:
D = Dull
S = Sharp / Stabbing
A = Annoyance
B = Burning
T = Tingling (Pins and Needles)
G= Grinding
N = Numb
C = Cramping
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Parent category: Medical