Pregnancy Intake

Pregnancy Intake
Name

First Name Last Name
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Appointment date
When is the Due Date? How many weeks pregnant are you?
Your birthdate and age
Your Ob-Gyn/ Midwife name and number
Have you had any complications or problems with this pregnancy?

Bleeding Cramping Amniotic fluid leakage Swelling High blood pressure Rapid weight gain Protein in urine Vision disturbances Severe nausea Vomiting Headaches Abnormal fetal growth, heart beats or movements High blood sugar
Do you have any medical conditions?

Diabetes Heart Liver Kidney Lung Convulsive disorders Uterine abnormallity Connective Tissue/collagen disorder
Are you currently experiencing any infection or disorder?

Cold Bladder infection Breast infection Skin irritation Yeast infection Varicose veins
Is your pregnancy considered high risk due to

Diabetes Hypertension Multiple pregnancy Previous complicated pregnancy Asthma Rh factor Genetic problems Under 20 years old Over 35 years old Fetal genetic disorders Exposures to hazardous materials
Is there relevant information about this pregnancy that I should know?
Where are you feeling pain or discomfort?
Which activities provide relief? Which activities aggravate it?
Which types of exercise are you doing during this pregnancy?
Are you allergic to any of the following?

Olive oil Jojoba oil Coconut oil Castor oil Lavender essential oil
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