Postpartum Questionnaire

Postpartum Questionnaire
CONFIDENTIAL PATIENT INFORMATION:
Name*

First Name:Last Name:
Baby's Birth Date:*

MonthDayYear
Date
Baby's Name*
Emergency Contact:
Please enter a valid phone number.
Emergency Relation:*
Emergency Phone:*
Please enter a valid phone number.
Are you also receiving care from any other health professionals during your postpartum period?*

YesNo

Please name them and their specialty:

Please describe labor and birth experience:
Please describe your postpartum experience currently:
Overall, how do you feel about your labor, birth, and postpartum experience thus far?
How are you currently nourishing your body?
Community: who are you able to lean on during this time for support?
How are you with setting boundaries with family and friends?
CURRENT HEALTH CONDITIONS
What health condition(s) are currently bringing you into our office?
When did the conditions first begin?*
How did the problem start?*

SuddenlyGraduallyPost-Injury
Is this condition:*

Getting worseImprovingIntermittentConstantUnsure
What makes the problem better?
What makes the problem worse?
Draw on Image
Patient Review of Systems
The nervous system controls and coordinates all organs and structures of the human body.

Please check the corresponding boxes for each symptom or condition you have experienced - including both past and present.
Patient Name:*

	Past	Present
Anxiety & Constant Stress
Focus & ADHD Challenges
Difficulty Sleeping
Low Energy & Fatigue
Depression & Mood Regulation Challenges
Lightheadedness & Dizziness
Vertigo
Tension Headaches
Migraines
Stiff Neck & Shoulders
Pain, Numbness, & Tingling in Arms and Hands
TMJ & Jaw Pain
Vision & Hearing Issues
Ear & Sinus Infections
Sore Throat & Strep
Strep & Upper Respiratory Infections
Allergies and Autoimmune Challenges
Chronic Inflammation
Acid Reflux, GERD, & Indigestion
Lack of Appetite
High Blood Pressure
Asthma
Chronic Chest Colds & Cough
Bronchitis & Pneumonia
Functional Heart Conditions
Gallbladder Pain & Issues
Stomach Ulcers and Pain
Blood Sugar Problems
Skin Conditions/Rash
Ulcerative Colitis/Crohn's Disease
Feelings of Guilt, Shame, or Hopelessness
IBS
Kidney Challenges
Gas Pain & Bloating
Gluten & Casein Intolerance
Constipation
Bladder & Urination Issues
Cysts & Endometriosis
Fertility Challenges
Racing Thoughts or Constant Worry
Hemorrhoids
Low Back Pain & Stiffness
Sciatica & Radiating Pain
Lumbopelvic/SI Joint Pain
Disc Degeneration
Leg Weakness & Cramps
Painful Intercourse
Poor Circulation & Cold Feet
Episiotomy or Tears During Birth
C-section Scar Tenderness
Epidural Residual Pain

How is your feeding journey going?
Your top three health goals during the postpartum period:
Health goal 1
Health goal 2
Health goal 3
How has chiropractic care impacted your birth and pregnancy?
Can we share your story on social media? We can take a picture with you or make itanonymous!*

Yes, and take a pic!Yes, but anonymous!Not yet!
ACKNOWLEDGEMENT & CONSENT
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

CONFIDENTIAL PATIENT INFORMATION: