Pregnancy Chiropractic Intake Form printable pdf download

Pregnancy Chiropractic Intake Form

DR. BARRY YOUNG

1508 Upper James St, Hamilton, ON L9B 1K3

DR. JENNIFER KRAGREN RO

Pregnancy Chiropractic Intake Form

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Primary Complaint:

What is your current concern?

Where do you feel discomfort?

How would you describe the pain?

(stabbing, dull, achy, stiff & tight, burning, pins and needles, etc.)

Does the pain travel to other parts of your body?

When did it occur?

How did it occur?

Is it getting better or worse, or staying the same?

Have you seen other health professionals for this concern?

Yes

If yes, whom, and what treatment did they use?

Have you taken medication for this complaint?

Yes

Have you ever experienced this complaint before?

Yes

If yes, when?

Did you receive any treatment at the time for this complaint?

Yes

Have you had x-rays in relation to the current complaint?

Yes

Is this an injury that occurred at work?

Yes

If yes, was it reported?

Yes

Is this an injury as a result of a motor vehicle accident?

Yes

If yes, is there a claim pending?

Yes

Have you seen a chiropractor previously?

If yes, when was your last treatment?

How far along into your pregnancy are you?

When is your baby’s due date?

Have you experienced any trauma during this pregnancy?

Have you had any evaluation procedures (ultrasound, amniocentesis, chorionic villus sampling)?

Dates and Reasons:

Have there been any stressful events in your life during this pregnancy?

Pregnancy Chiropractic Intake Form