PostPartum Health Questionnaire

PostPartum Health Questionnaire
Patient Name*
Age*
Date of birth*

MonthDay Year
Date
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Gender
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Marital Status*

SingleMarriedDivorcedWidowed
Employer
Occupation
Spouse's Name
Who may we thank for referring you to our office?
CHIROPRACTIC HISTORY
Have you been evaluated or adjusted by a Chiropractor before?*
If yes, Name of Doctor, and date of last visit
What was the reason for those visits?
Were you satisfied with your care?
REASON FOR VISIT
Reason for this visit*

wellnesspain complaintnutritionpostpartum support
Please describe
What date did this begin?
Did this problem start

suddenlygraduallyafter an injury
Has this problem

gotten worsestayed the samegotten bettercomes and goes
What makes the problem better?
What makes the problem worse?
Does this problem interfere with:

Worksleepdaily routineother
Please describe:
Please describe the quality of pain, mark all that apply

dullachesharptinglingnumbshooting
Does the pain radiate/travel

yesno
If yes, to where?
Rate the severity of the pain (0=no pain, 10=ER visit)
Does the pain change throughout the day? If yes, please explain:
Have you seen other doctors for this complaint?
Type of treatment received:
HEALTH HABITS
Do you smoke*

yesnoused to
How many packs a day?
Do you drink alcohol?*

yesno
How many drinks a week?
Do you drink coffee, tea or soda?*

yesno
How many cups a day?
How often do you exercise? What do you do for exercise?*
Do you experience anxiety or mood disorders? If so when did they begin?*
Did you ingest your placenta postpartum*

yesno
Are you currently breastfeeding?*

yesno
How would you rate your diet?*

Poorfairgoodexcellentcould be better
Please list any supplements you are taking:*
How many hours of sleep do you get a day? Quality of sleep?*
Do you wear:

heel liftssole liftsinner solesarch supports
Have you been diagnosed with a chronic illness? (i.e. heart disease, diabetes, cancer, autoimmune disease, etc.)*
Please list any health conditions your family members have been diagnosed with: Member and condition:*
Family Member and condition:
Family Member and condition:
REVIEW OF SYSTEMS
Please mark any of the following symptoms you have experienced with the last 6 months:*

headachesneck painringing in the earsdizzinessvertigofeverear achesore throatweight lossweight gainblurred visionchest painfatiguemood changemidback paindifficulty breathingallergiessinus problemschronic coldcongestionasthmaADHDHigh blood pressurenumbness and tingling in armsbronchitisdigestion issueskidney stonesstomach problemsconstipationirritable bowelmenstrual paiinlow back paintingling/numbness in legsreproductive problems
CURRENT MEDICATIONS
Please list any medications you take and your dosage:*
Any trauma during this pregnancy? If yes, please explain:*
Any hospitalization during this pregnancy? If yes, please explain:*
Any medication taken during this pregnancy, including over the counter and supplements?*
Any fertility treatments? If yes, please explain:*
PREVIOUS PREGNANCIES
Number of previous pregnancies:*
Number of previous births:*
Number and ages of children:*
At what weeks were your children born?*
Where did your previous births take place?
Please list any medications or anesthesia used during previous births:*
Please mark interventions used in previous births:*

breaking of watervacuum extractionEspisiotomycesarean sectionmembranes strippedforceps
How long was your previous labor? Total and 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 *
Personnal:*
MENSTRUAL CYCLE
Are you:*

cyclingcycle has not returned yet
Are you currently on birth control?*

yesno
What type?
Do you:

experience painful periodshave irregulars cyclesheavy bleedingexperience infertilityannual mammograms
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 or relieving the cause of the problem as well as the symptom or painCOMPREHENSIVE CARE: Get out of pain, correct the underlying cause, and function at an optimal levelI WANT THE DOCTOR TO SELECT THE 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 addressed yet, please write them below in the space below:
CONSENT for examination and care: Please Read Carefully
In order for my health prefessional as indicated below to make a determination on the suitability of my case for care, 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 the Chiropractor, about the nature and purpose of the examination process. I understand that there may be remotely associated risks with examinations, as ther 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 by signing this form, the chiropractor continues to be obligated for best practices delivered in my interest.

Doctors of Chiropractic: Dr Stephanie Wigner DC, Dr Monika Luto DC

Addresses: 2621 Bridge Ave Point Pleasant NJ 08742

43 Main Street Avon By The Sea NJ 07717
Printed Name:*
Date*

MonthDay Year
Date
Signature:*

Clear
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, therfore 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 charfed 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:

PostPartum Health Questionnaire

CHIROPRACTIC HISTORY

REASON FOR VISIT

HEALTH HABITS

REVIEW OF SYSTEMS

CURRENT MEDICATIONS

PREVIOUS PREGNANCIES

MENSTRUAL CYCLE

GOALS FOR YOUR CARE

CONSENT for examination and care: Please Read Carefully

24 HOUR CANCELLATION POLICY