Pregnancy Chiropractic Intake Form Page 2
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1
2DR. BARRY YOUNG
1508 Upper James St, Hamilton, ON L9B 1K3
DR. JENNIFER KRAGREN RO
Pregnancy Chiropractic Intake Form
Page 2 of 2
What type of birth care provider are you planning on using?
Midwife
OB/Gyn
Medical Doctor
Other
Where do you plan on delivering?
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 caesarian sections?
Have there been any complications during your previous deliveries?
Yes
No
Was labour induced/use of Pitocin?
Yes
No
Unknown
Did your care provider rupture your membranes?
Yes
No
Unknown
Was there any back pain during labour?
Yes
No
Did you receive an epidural?
Yes
No
Were there any operative devices used?
Yes
No
Forceps
Vacuum
Have you experienced any of the following symptoms during this pregnancy or a previous pregnancy?
Nausea/”Morning Sickness”
Pain down Posterior Leg (sciatica)
Headaches
Heartburn/Indigestion
Carpal Tunnel (numbness in hands/fingers)
Constipation
Pins/Needles in the front side of your leg
Swelling of Ankles, Legs and Feet
Pain in your Pubic Bone
Hemorrhoids
Leg Cramps
Facial Paralysis
Breech Presentation
Gestational Diabetes
Chronic Fatigue
Low/Mid Back Pain
Are you interested in:
Acute Pain Care: We can provide relief for the immediate pain you are feeling. It is important to remember that your body is
constantly changing and adapting for the duration of your pregnancy and you are likely to experience a reoccurrence of this pain.
Maintenance Care: We can provide ongoing care for the duration of your pregnancy to prevent your pain from getting worse if
it returns.
Wellness Care: We can ongoing care for the duration of your pregnancy to prevent your pain from getting worse if it returns, as
well as prevent many other common conditions associated with pregnancy. Wellness care has also been shown to reduce
labour times and intensity of pain for women who are adjusted on a regular schedule.
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