ACUNEEDLING Initial Consult
Midwife Tara
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Estimated Due Date
*
-
Day
-
Month
Year
Date
What treatments do you need assistance in?
*
Emotional support (Anxiety, stress, depression)
Nausea & Vomiting
Heartburn
Constipation
Haemorrhoids, vulval varices & varicose veins
Insomnia (Difficulty sleeping or staying asleep)
Itching in pregnancy
Thrush
Breech Position
Posterior Position
External Cephalic Version (ECV)
Oedema (Swelling)
Anaemia
Threatened Miscarriage
IUGR (Intrauterine Growth Restriction)
PIH (Pregnancy Induced Hypertension)
Back, hip, symphysis pubis pain and sciatica
Prebirth Treatment
Labour Activation
Postnatal Mother Warming
After birth pains
Mastitis
Unsure & you need my help!
IUFD
Contact Number:
*
Format: 0400000000.
E-mail
How would you like me to contact you?
*
Text Message
Email
Address:
*
Street Address
Suburb
City
Postcode
Special parking considerations?
Where will you be birthing your baby? Who is your care provider?
*
Do you have any pregnancy complications?
*
Is this your first pregnancy? If not, please tell me about your previous pregnancy and birth history.
*
Do you have any past medical history? Any previous surgery?
*
Do you have any allergies?
*
Yes
No
Please list them here...
Taking any medications, currently?
*
Yes
No
Please list them here...
Who can I thank for the referral? How did you find me?
*
In case of emergency
Emergency Contact:
*
First Name
Last Name
Relationship
*
Contact Number
*
Format: 0400000000.
Have you ever had acuneedling or any acupunture treatment before?
*
Yes
No
Look forward to seeing you soon xx
Contact: IG @motherwithin_ | motherwithin@outlook,com
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