Pregnancy New Patient

Pregnancy Health Questionnaire
Name*

First Name Last Name
Age*
Date of birth*

MonthDay Year
Date
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email address*
example@example.com
Phone Number*
Please enter a valid phone number.
Gender*
Marital Status*
Occupation
Employer
Spouse's Name
Spouse's Employer
Insurance Company
Insurance ID Number
Insured Name
Insured Date of Birth

MonthDay Year
Date
Who may we thank for referring you to our office? *
CURRENT PREGNANCY
Due Date/Week*

MonthDay Year
Date
I am in myblanks* week of pregnancy.
Pre pregnancy Weight*
Current weight*
Height
Childbirth preparation: Bradley Method yes/no*
La Maze yes/no*
Midwifery*
Chlidbirth Caregivers:*
Caregiver's Name and Phone Number*
What was your blood pressure prior to pregnancy?*
Current blood pressure*
I plan on giving birth at a (mark one)*

hospitalhomebirthing center
Name of Hospital or Birthing Center*
What position do you sleep in?*

SideBackStomach
Any traumas during this pregnancy? If yes, explain:*
Any hospitalizations during this pregnancy? If yes, explain:*
Any medications taken during this pregnancy, including over the counter medications and supplements?*
Any fertility treatments? If yes, explain:*
Are you a smoker? How many packs per day?*
Do you drink coffee, tea or soda? If yes, how many cups per day?*
How many cups of water per day?*
What are you doing for exercise?*
Are you eating a balanced diet?*
Are you sleeping at least 8 hours a day?*
Are you planning on breastfeeding post delivery?*
Are you currently working?*
Do you sit the majority of the day?*
Have you had any pregnancy evaluation procedures performed? (i.e. ultrasound, amniocentesis, chronic villlus sampling, etc If yes, please explain:*
What is your reason for seeking chiropractic care (circle all that apply)*

Breech presentation/MalpositionBackacheHeadacheTraumaIncrease chance of healthy labor and deliveryWellness VisitPain reliefHealthier immune systemOther
What are your most significant fears associated with this pregnancy or birth process?*
PREVIOUS PREGNANCIES
Number of previous pregnancies*
Number of previous births*
Names and ages of children*
At what weeks were your children born?*
Where did your previous births take place?*
Please list medications or any anesthesia used during previous births:*
Please mark interventions used in previous births:

Episiotomycesarean sectionbreaking of watermembranes strippedforcepsvacuum extraction
How long was your previous labor? Total*
Time before you pushed
Did you have chiropractic care during your previous pregnancies?*
Describe your stress level on a scale of 1-10 (1=none/10=extreme) : Occupational:*
Personal*
Mark the position of your baby*

head downposteriortransversebreechnot sure
Please mark all symptoms you have ever had, even if they do not seem related to your current problem:

HeadachesPins and needles in extremitiesLoss of balanceDizzinessSinus conditionsBack painNumbness in extremitiesIrritabilityRinging in the earsNervousnessDepressionNeck painUpset stomachLoss of tasteCold sweatsFatigueSleeping problemsReproductive disordersMenstrual painUlcersConstipationConcussionHot flashesFaintingHeartburnMood SwingsThyroid issueStiff neck
What is your biggest fear as you approach birth?*
If you are experiencing current, or ongoing stress please explain
Do you practice stress management techniques? If so, please explain
GOALS FOR YOUR CARE
People seek chiropractic care for a variety of reasons. Some go for relief of pain, some go to correct the cause of pain and others go for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please mark the type of care desired so that we may be guided by your wishes whenever possible. PLEASE PICK ONE.*

Relief Care: Symptomatic relief of pain or discomfortCorrective Care: Correcting and relieving the causes of the problem as well as the symptom or pain.Comprehensive Care: Get out of pain, correct the underlying cause, and function at an optimal levelI want the Doctor to select they type of care for my condition
If there are any issues that you are experiencing, or that you have concerns about that have not been ddressed yet, please write them below in the space below
CONSENT for examination and care: Please Read Carefully

Inorder for my health professional as indicated below to make a determination on the suitability of my case forcare, I acknowledge and understand that I must complete a thorough evaluation. I do hereby request and consent to the performance of such an evaluation by the person(s) named below, or any party authorized to do so by that person.

I have had the opportunity to discuss with the Doctor of Chiropractic indicated below, or with any party authorized to do so by that Chiropractor, about the nature and purpose of the examination process. I understand that there may be remotely associated risks with examinations, as there are with any and all healthcare treatments. In healthcare, the matter of whether any treatment is appropriate or not is determined by looking at the level of risk and comparing this with the level of expected benefit. I understand that I may ask the doctor to stop the examination at any time. I also understand that by signing this form, the chiropractor continues to be obligated for best practices delivered in my interests.
Name*
Signature*

Clear
Date*

MonthDay Year
Date
Doctors of Chiropractic: Dr. Stephanie Wigner, DC, Dr. Monika Luto, DC Address: 2621 Bridge Ave Point Pleasant NJ 08742/ 43 Main Street Avon By The Sea 07717
THANK YOU FOR CHOOSING CIRCLE OF LIFE CHIROPRACTIC DURING THIS SPECIAL TIME IN YOUR LIFE!
Our goal is to help women express their innate abilities to have the birth they want and deserve
24 HOUR CANCELLATION POLICY
Due to the high volume of appointments and our commitment to having your wait time remain short, we have decided to implement a 24 hour cancellation policy. This allows us to fit everyone into our schedule that needs to be seen while respecting your time. We've never wanted to be an office that double books appointments, therefore causing you to wait 20+ minutes to be seen. However, our schedule is often full and the last minute cancellations are unfair to those needing appointments whom we've turned away. Every family member that is cancelled less than 24 hours in advance will be charged a $50 cancellation fee. We appreciate you and want to continue to serve you at a high level.

To cancel or reschedule your appointment, please call us at 732-295-4000 or text us at 732-701-7407. If you cannot reach us or it is outside office hours please leave a detailed message with your name and phone number. We will return your call promptly.

By signing below, you acknowledge that you have read and understand the cancellation policy.
Name*
Signature*

Clear
Date*

MonthDay Year
Date
Should be Empty:

CURRENT PREGNANCY

PREVIOUS PREGNANCIES

GOALS FOR YOUR CARE

THANK YOU FOR CHOOSING CIRCLE OF LIFE CHIROPRACTIC DURING THIS SPECIAL TIME IN YOUR LIFE!

24 HOUR CANCELLATION POLICY