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New Patient Form – Pregnancy

Home/New Patient Form – Pregnancy
New Patient Form – PregnancyKurt Abel2021-09-23T19:25:29+00:00

Step 1 of 11

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Patient Data

Name(Required)
Date(Required)

Mailing Address

Address(Required)
Date of Birth(Required)
How would you like to receive appointment reminders?(Required)

Questions Regarding Your Pregnancy

Is this your first pregnancy?(Required)
Are you under the care of an
Have you ever been under chiropractic care?(Required)
Have you been under chiropractic care during pregnancy?(Required)
Are you taking prenatal vitamins?(Required)
Are you taking any medications?(Required)

Insurance Information

Do you have health insurance?(Required)

Billing Address

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Date
Date

Medical History

Have you been treated for any condition in the last year?(Required)
Date of last physical exam(Required)
Have you had X-rays taken?(Required)

Have you ever:

Broken bones?(Required)
Been hospitalized?(Required)
Been in an auto accident?(Required)
Had sprains/strains?(Required)
Been struck unconscious?(Required)
Had surgery?(Required)

Family History

Your Current Condition

Do you experience pain every day?(Required)
Do your symptoms interfere with daily life?(Required)
Does pain wake you up at night?(Required)
Are your symptoms worse during certain times of the day?(Required)
Do changes in weather affect your symptoms?(Required)
Do you wear orthotics?(Required)

Current Habits

Alcohol(Required)
Coffee(Required)
Tobacco(Required)
Drugs(Required)
Exercise(Required)
Sleep(Required)
Appetite(Required)
Soft Drinks(Required)
Water(Required)
Salty Foods(Required)
Sugary Foods(Required)
Artificial Sweeteners(Required)

Please check if you currently have or have a history of:

Alcoholism
Allergies
Anemia
Arteriosclerosis
Arthritis
Asthma
Back Pain
Breast lump
Bronchitis
Bruise Easily
Cancer
Chest Pain/Conditions
Cold extremities
Constipation
Cramps
Depression
Diabetes
Digestion Problems
Dizziness
Ears Ring
Excessive Menstruation
Eye Pain/Difficulties
Fatigue
Frequent Urination
Headache
Hemorrhoids
High Blood Pressure
Hot Flashes
Irregular Heart Beat
Irregular Cycle
Kidney Infection
Kidney Stones
Loss of Balance
Loss of Memory
Loss of Smell
Loss of Taste
Morning Sickness
Neck Pain or Stiffness
Nervousness
Nosebleeds
Pacemaker
Polio
Poor Posture
Sciatica
Shortness of breath
Sinus Infection
Sleep problems/insomnia
Spinal Curvatures
Stroke
Swelling of ankles
Swollen Joints
Thyroid Condition
Ulcers
Varicose Veins
Venereal Disease
Other:
Consent(Required)
Please use your mouse or finger to sign in this box.

About Us

We want to empower you to take control of your health as it is our desire to assist you and your family in achieving optimum health, wellness, and longevity.

Lander Chiropractic

1203 Imperial Hwy #100
Brea, CA 92821
Phone: (714) 931-0475
Fax: (714) 582-1727

Main Office - Brea

Click to open a larger map

Office Hours

Monday - Saturday by appointment only. No walk-ins.

Our Services

Pages

  • Acupuncture
  • Bloom Attendee Raffle
  • Chiropractic Care
  • Chiropractic Care for Children
  • Chiropractic Care for Sports Injuries
  • Home Exercise Recommendations
  • New Acupuncture Patient Form
  • New Patient Form – Personal Injury
  • New Patient Form – Pregnancy
  • New Patient Health History Form
  • New Pediatric Patient Health History Form
  • Pregnancy Care
  • Safety & Support – Your Health & Concerns Matter To US: COVID-19 Response
  • Story Time With Dr. A

Connect With Us!

We are ICPA Certified

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