Pregnancy Questionnaire
Patient Name
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PREVIOUS BIRTH EXPERIENCE
Is this your first pregnancy? (Yes/No) If not, please tell us about your previous pregnancy and/or birth experience(s).
Do you plan to follow the same plan as your previous delivery? (Yes/No) If no, what would you like to change?
CONCEPTION & EARLY PREGNANCY
When is your expected or calculated due date?
-
Month
-
Day
Year
Date
Did you have any difficulty conceiving? (Yes/No) If yes, please explain:
Have you ever used any form of hormonal or oral contraceptives? (Yes/No) If yes, which ones and for how long?
When was your last menstrual cycle?
Date
What was your pre-pregnancy weight?
lbs
Current weight?
lbs
Have you experienced morning sickness? (Yes/No) If yes, please explain:
CURRENT HEALTH CONDITIONS
What type of exercises are you currently performing?
Please tell us about your current diet, what you eat daily, and any dietary restrictions.
Have you taken any medications or supplements during your pregnancy? (Yes/No) If so, what type and which brand?
Have you had any slips, falls, or any other physical trauma during the pregnancy? (Yes/No) If yes, please explain:
Have you had any major emotional stressors during your pregnancy? (Yes/No) If yes, please explain:
Back
Next
YOUR BIRTH PLAN
Your top three 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?
Who is your birth provider?
Do you intend to have a doula or birth coach present? (Yes/No) If yes, what is her name?:
Do you wish to have a natural vaginal labor and delivery? (Yes/No) If not, what concerns do you have?
YOUR POST-BIRTH PLAN
Do you plan on breastfeeding your child?
Yes
No
What do you intend to do for vaccines?
Is there anything else you'd like to tell us about your pregnancy or birth plan?
What would you like to gain from chiropractic care during your pregnancy?
Are there any burning questions you want to be sure to ask today?
Submit
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm