trumotion.org - Adult Patient Questionnaire Pregnancy Pack Form

Adult Patient Questionnaire, Pregnancy Pack
Confidential Patient Information
Name

First NameLast Name
Date

MonthDayYear
Date
SSN
Date of birth

MonthDayYear
Date
Sex
Occupation
# of children
Marital status
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Height
Weight
Email
example@example.com
Phone Number
Please enter a valid phone number.
Other Phone Number
Please enter a valid phone number.
Emergency Contact
Emergency Relation
Emergency Phone
Please enter a valid phone number.
How did you hear about us?
Who is your primary care physician
Date and reason for your last doctor visit?
Are you receiving care from any other health professionals?

YesNo
If yes, please name them and their specialty
Please note any significant family medical history
Current Health Conditions
What health condition(s) bring you into our office?
Please describe where you are experiencing pain or discomfort

Right shoulderLeft shoulderRight armLeft armRight hipLeft hipRight kneeLeft kneeRight ankleLeft ankleNapeRight shoulder bladerLeft shoulder bladerMiddle backLow backRight elbowLeft elbow
Please describe where you experienced pain or discomfort

Right shoulderLeft shoulderRight armLeft armRight hipLeft hipRight kneeLeft kneeRight ankleLeft ankleNapeRight shoulder bladerLeft shoulder bladerMiddle backLow backRight elbowLeft elbow
Have you received care for this problem before?

YesNo
If yes, explain
When did the condition(s) first begin?

MonthDayYear
Date
How did the problem start?

SuddenlyGraduallyPost-Injury
In this condition

Getting worseImprovingIntermittentConstantUnsure
What makes the problem better?
What makes the problem worse?
Your Health Goals
What are your top three health goals?
Chiropractic History
What would you like to gain from chiropractic care?

Resolve existing condition(s)Overall wellnessBoth
Have you ever visited a chiropractor?

YesNo
If yes, what is their name?
What is their specialty?

Pain ReliefPhysical Therapy & RehabNutritionSubluxation-basedOther
Do you have any health concerns for other family members today?
TRAUMAS: Physical Injury History
Have you ever had any significant falls, surgeries or other injuries as an adult?

YesNo
If yes, please explain
Notable childhood injuries?

YesNo
If yes, please explain
Youth or college sports?

YesNo
If yes, list major injuries
Any past auto accidents?

YesNo
If yes, list major injuries
How often do you exercise?

None1-3x per weekO4-6x per weekDaily
What types of exercise?
How do you normally sleep?

BackSideStomache
Do you wake up?

Refreshed and readyStiff and tired
Do you commute to work?

YesNo
If yes, how many minutes per day?
List any problems with flexibility (Ex: putting on shoes/socks,...)
How many hours per day do you typically spend sitting at a desk?
On a computer, tablet or phone?
TOXINS: Chemicals & Environmental Expose

Please rate your CONSUMPTION for each

	1=None	3=Moderate	5=High
Alcohol
Water
Sugar
Dairy
Gluten
Processed Foods
Artificial Sweeteners
Sugary Drinks
Cigarettes
Recreational Drugs

Please list any drugs/ medications/vitamins/ herbs or other that you are taking and why?
THOUGHTS: Emotional Stresses & Challenges

Please rate your STRESS for each

	1=None	3=Moderate	5=High
Home
Work
Life
Money
Health
Family

Acknowledgement & Consent
Patient Signature

Clear
Date

MonthDayYear
Date
Pregnancy Questionnaire
Patient Name
Date

MonthDayYear
Date
Previous Birth Experience
Is this your first pregnancy?

YesNo
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?

YesNo
If not, what would you like to change?
Conception & Early Pregnancy
When is your expected calculated due date?

MonthDayYear
Date
Did you have any difficulty conceiving?

YesNo
If yes, please explain
Have you ever used any form of hormonal or oral contraceptives?

YesNo
If yes, which ones, and for how long?
When was your last menstrual cycle?
What was your pre-pregnancy weight?
Current Weight
Have you experienced morning sickness?

YesNo
If yes, please explain
Current Health Conditions
What type of exercise(s) are you currently performing?
Please tell us your current diet, and any dietary restrictions.
Have you taken any medications or supplements during your pregnancy?

YesNo
If yes, please explain
Have you had any slips, falls, or other physical traumas during the pregnancy?

YesNo
If yes, please explain
Have you had any major emotional stressors during the pregancy?

YesNo
If yes, please explain
Your Birth Plan
What are your top three goals for this pregnancy?
Do you currently have a birth plan?

YesNo
If yes, please explain
Are you taking any prenatal or birthing classes?

YesNo
If yes, please explain
Who is your OB/GYN or midwife?
Will they be present for delivery?

YesNo
Who is your birth provider?
Do you intend to have a doula or birth coach present?

YesNo
If yes, please explain
Do you wish to have a natural vaginal labor and delivery?

YesNo
If not, what concerns do you have?
Your Post Birth Plan
Do you plan on breastfeeding your child?

YesNo
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?
Patient Review of Systems
THE NERVOUS SYSTEM CONTROLS AND COORDINATES ALL ORGANS AND STRUCTURES OF THE HUMAN BODY (Please check the coressponding boxes for each symptom or condition you have experienced-including both past and present)

Region: Cervical.

Functions:
- Autonomic Nervous System
- ENT System
- Vision, Balance & Coordination
- Speech
- Immune System
- Digestive System
- Nerve Supply to Shoulders, Arms & Hands
- Sympathetic Nucleus
- Metabolism
PLEASE SELECT THE SYMPTOMS YOU EXPERIENCED

Colic & Excessive CryingEar & Sinus InfectionsAllergies & CongestionImmune DeficiencyHeadache & MigrainesVertigo & DizzinessSore Throat & StrepSwollen Tonsils & AdenoidsVison & Hearing IssuesLow Energy & FatigueDifficulty SleepingPain, Numbness & Tingling in Arms to HandsEpilepsy & SeizuresSensory & SpectrumADD/ADHDFocus & Memory IssuesAnxiety & StressBalance & CoordinationSpeech IssuesTMJ/Jaw PainStiff Neck & ShouldersDepressionHigh Blood PressurePoor Metabolism & Weight Control
PLEASE SELECT THE SYMPTOMS YOU ARE EXPERIENCING

Colic & Excessive CryingEar & Sinus InfectionsAllergies & CongestionImmune DeficiencyHeadache & MigrainesVertigo & DizzinessSore Throat & StrepSwollen Tonsils & AdenoidsVison & Hearing IssuesLow Energy & FatigueDifficulty SleepingPain, Numbness & Tingling in Arms to HandsEpilepsy & SeizuresSensory & SpectrumADD/ADHDFocus & Memory IssuesAnxiety & StressBalance & CoordinationSpeech IssuesTMJ/Jaw PainStiff Neck & ShouldersDepressionHigh Blood PressurePoor Metabolism & Weight Control
REGION: UPPER THORACIC

Functions:
- Upper G.I
- Respiratory System
- Cardiac Function
PLEASE SELECT THE SYMPTOMS THAT YOU EXPERIENCED.

Reflux / GERDChronic Colds & CoughAsthmaBronchitis & PneumoniaFunctional Heart Conditions
PLEASE SELECT THE SYMPTOMS THAT YOU ARE EXPERIENCING

Reflux / GERDChronic Colds & CoughAsthmaBronchitis & PneumoniaFunctional Heart Conditions
REGION: MID THORACIC

Functions:
- Major Digestive Center
- Detox & Immuniny
PLEASE SELECT THE SYMPTOMS THAT YOU EXPERIENCED

Gallbladder Pain / IssuesJaundiceFeverIndigestion & HeartburnStomach Pains & UlcersBlood Sugar Problems
PLEASE SELECT THE SYMPTOMS THAT YOU ARE EXPERIENCING

Gallbladder Pain / IssuesJaundiceFeverIndigestion & HeartburnStomach Pains & UlcersBlood Sugar Problems
REGION: LOWER THORACIC

Functions:
- Stress Response
- Filtration & Elimination
- Gut & Digestion
- Hormonal Control
PLEASE SELECT THE SYMPTOMS THAT YOU EXPERIENCED

Behavior IssuesHyperactivityChronic FatigueChronic StressAllergies & EczemaSkin Conditions / RashKidney ProblemsGas Pain & Bloating
PLEASE SELECT THE SYMPTOMS THAT YOU ARE EXPERIENCING

Behavior IssuesHyperactivityChronic FatigueChronic StressAllergies & EczemaSkin Conditions / RashKidney ProblemsGas Pain & Bloating
REGION: LUMBAR, SACRUM & PELVIS

Functions:
- Lower G.I (Absorption & Motility)
- Gut-Immune System
- Major Hormonal Control
PLEASE SELECT THE SYMPTOMS THAT YOU EXPERIENCED

ConstipationChrohn's, Colitis & IBSDiarrheaBed-wettingBladder & Urination IssuesCramps & Menstrual IssuesCysts & EndometriosisInfertilityImportencyHermorrhoidsSciatica & Radiating PainLumbopelvic/ST Joint PainHamstring TightnessDisc DegenerationLeg Weakness & CrampsPoor Circulation & Cold FeetKnee, Ankle & Foot PainWeek Anke & ArchesLower Back PainGlutein & Casein Intolerance
PLEASE SELECT THE SYMPTOMS THAT YOU ARE EXPERIENCING

ConstipationChrohn's, Colitis & IBSDiarrheaBed-wettingBladder & Urination IssuesCramps & Menstrual IssuesCysts & EndometriosisInfertilityImportencyHermorrhoidsSciatica & Radiating PainLumbopelvic/ST Joint PainHamstring TightnessDisc DegenerationLeg Weakness & CrampsPoor Circulation & Cold FeetKnee, Ankle & Foot PainWeek Anke & ArchesLower Back PainGlutein & Casein Intolerance
Patient Name
Date

MonthDayYear
Date
Should be Empty:

Adult Patient Questionnaire, Pregnancy Pack

Confidential Patient Information

Current Health Conditions

Your Health Goals

Chiropractic History

TRAUMAS: Physical Injury History

TOXINS: Chemicals & Environmental Expose

THOUGHTS: Emotional Stresses & Challenges

Acknowledgement & Consent

Pregnancy Questionnaire

Previous Birth Experience

Conception & Early Pregnancy

Current Health Conditions

Your Birth Plan

Your Post Birth Plan

Patient Review of Systems