Pregnant New Patient Intake
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Insurance
Please fill out all fields if you would like us to bill your insurance.
Do you have health insurance that you would like to use?
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If yes, please list the type of insurance that you have.
Who is the primary subscriber and what is their relation to you (spouse, parent, etc)?
What is the birth date of the primary subscriber?
Please list the Subscriber Id/Member ID
What is the group number?
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Please Tell Us Why You're Here
Reason for Visit
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Wellness Care
Pain
Work Related Injury
Automobile Related Injury
Date Injury / Condition Began
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Month
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Day
Year
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Were you treated for this condition at the hospital or by another doctor?
Yes
No
If Yes to above, please list the hospital and/or all doctors you have seen for this condition
Has your condition
Become worse
Become better
Remained the same
My Condition interferes with
Work
Sleep
My Daily routine
Recreational activities
other
Have you had similar condition in the past?
Yes
No
If Yes to above, please explain
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Tell Us About Your Discomfort
Use the corresponding numbers on the diagram to indicate where your pain/discomfort is. Use the sliders to rate the severity of your pain on a scale of 1-10 with 10 being the most severe.
1 (headache)
2 (right shoulder pain)
3 (left shoulder pain)
4 (right elbow pain)
5 (left elbow pain)
6 (right wrist pain)
7 (left wrist pain)
8 (right hip pain)
9 (left hip pain)
10 (right knee pain)
11 (left knee pain)
12 (right ankle pain)
13 (left ankle pain)
14 (right foot pain)
15 (left foot pain)
16 (neck pain)
17 (shooting pain into left arm)
18 (shooting pain into right arm
19 (mid back pain)
20 (low back pain)
21 (shooting pain into left leg)
22 (shooting pain into right leg)
Are you experiencing any numbness or tingling?
Are you experiencing any muscle weakness?
Other Complaints
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Activities of Daily Living
How does this condition interfere with your life and ability to function.
No Effect
Mild Effect
Moderate Effect
Severe Effect
Sitting
Rising out of chair
Standing
Walking
Lying down
Bending over
Climbing Stairs
Getting in and out of a car
Driving a car
Caring for family
Grocery shopping
Household chores
Lifting objects
Reaching overhead
Showering or bathing
Dressing myself
Sex life
Getting to sleep
Concentrating
Exercising
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Past Medical History
Please select all that you have or have had in the past.
Please check all that you have or have had in the past.
Allergies
Alcoholism
Anemia
Arteriosclerosis
Arthritis
Asthma
Back Pain
Breast Lump
Bronchitis
Bruise Easily
Cancer
Chest Pain
Cold Extremities
Constipation
Cramps
Depression
Diabetes
Digestive Problems
Dizziness
Fatigue
Frequent Urination
Headache
Hemorrhoids
High Blood Pressure
Hot Flashes
Irregular Heart Beat
Menstrual Problems
Kidney Stones
Loss of Memory
Loss of Balance
Nosebleeds
Pacemaker
Polio
Prostate Problems
Sciatica
Shortness of Breath
Sinus Infection
Sleep Difficulties
Stroke
Swollen Joints
Thyroid Condition
Tuberculosis
Ulcers
Venereal Disease
AIDS
Epilepsy
Glaucoma
Gout
Heart Disease
Hepatitis
Multiple Sclerosis
Osteoporosis
Scoliosis
Neck Pain
Foot / Ankle Pain
TMJ
Poor Posture
Anxiety
Numbness & Tingling
Sleep Apnea
Emphysema
Anorexia / Bulemia
Ringing in Ears
Hearing Loss
Hypoglycemia
Low Energy
Low Libido
Erectile Dysfunction
Other
Please tell us about any surgeries you have had in the past. Please include dates with each procedure.
Please list all medications that you are currently taking (please include both prescription and over the counter)
Please list any medical allergies you have.
Please list any supplements that you are currently taking.
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Women's Health- Pregnancy
How many weeks pregnant are you? (Please also list your due date)
*
Is this your first pregnancy? (If no, please list the #)
*
If this is not your first pregnancy, please briefly describe your previous birth experience.
Did you have any trouble trying to conceive? (If yes, what measures did you take?)
Have you experienced morning sickness?
Have you experienced any pain or discomfort during this pregnancy? (if yes, please describe)
Have you taken (or do you plan to take) child birth classes?
Are you interested in natural childbirth? (low intervention, drug-free)
Do you have a birth plan?
Who is your birth care provider and where will you deliver?
Have you hired a birth doula?
Do you know the position of the baby? (head down, transverse, breech).
Do you have any concerns about this pregnancy or delivery?
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Lifestyle
Rate your daily level of stress on a scale of 0 - 10 (10 is highest level of stress)
Rate the quality of your diet on a scale of 0 - 10 (10 is excellent)
Do you exercise regularly?
If yes, please explain what you do and how often.
On a typical day, how much water do you drink?
How many hours do you sleep each night?
What position do you typically sleep in? (Back, Side or Stomach?)
How much stretching do you do?
Would you like more information on:
Nutrition/Supplments
Stretches/Exercise
Proper Ergonomics
Chiropractic Care for Kids
Chiropractic History
Tell us about your experience with chiropractic
Have you ever been to a chiropractor before?
If yes, who was your chiropractor?
When was your last visit?
Briefly describe your experience.
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Patient's Name
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First Name
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INFORMED CONSENT TO CHIROPRACTIC CARE
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Date
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Month
-
Day
Year
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Patient's Name
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First Name
Last Name
Patient's Signature
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Date
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Patient's Name
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First Name
Last Name
Patient's Signature
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