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New Patient Form – Pregnancy
Home
/
New Patient Form – Pregnancy
New Patient Form – Pregnancy
Kurt Abel
2021-09-23T19:25:29+00:00
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Patient Data
Name
(Required)
First
Last
Date
(Required)
Month
Day
Year
Email
(Required)
Mailing Address
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
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Belarus
Belgium
Belize
Benin
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Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Cell Phone
Home Phone
Referred By
Age
(Required)
Date of Birth
(Required)
Month
Day
Year
Social Security Number
(Required)
Number of Children
(Required)
Occupation
(Required)
Employer
Marital Status
(Required)
Married
Divorced
Separated
Widowed
Single
Spouse's Name
(Required)
Spouse's Occupation
(Required)
Spouse's Employer
(Required)
Spouse's Health Status
(Required)
Emergency Contact
(Required)
Emergency Contact Phone
(Required)
How would you like to receive appointment reminders?
(Required)
email
text
Questions Regarding Your Pregnancy
Is this your first pregnancy?
(Required)
Yes
No
If this is not your first pregnancy, please list number of pregnancies
(Required)
If this is not your first pregnancy, please list number of children
(Required)
Date of Last Menstrual Cycle
(Required)
Due Date?
(Required)
Are you under the care of an
OB/GYN
Midwife
Name?
(Required)
Please describe any current complaints (if none, please enter N/A):
(Required)
Have you ever been under chiropractic care?
(Required)
Yes
No
Have you been under chiropractic care during pregnancy?
(Required)
Yes
No
Are you taking prenatal vitamins?
(Required)
Yes
No
Are you taking any medications?
(Required)
Yes
No
Please list any medications:
(Required)
What is your birth plan?
(Required)
Insurance Information
Name of party responsible for payment
Phone Number
Do you have health insurance?
(Required)
Yes
No
Name of Company
(Required)
Insurance Company Name
(Required)
Contact Name
(Required)
Phone Number
(Required)
Claim #
Billing Address
Name of the Insured
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.
Patient's Signature
(Required)
Date
Month
Day
Year
Spouse's or Guardian's Signature
Date
Month
Day
Year
Medical History
Have you been treated for any condition in the last year?
(Required)
yes
no
Please describe
(Required)
Date of last physical exam
(Required)
Month
Day
Year
Have you had X-rays taken?
(Required)
yes
no
Where were the X-rays taken?
(Required)
Have you ever:
Broken bones?
(Required)
yes
no
Breifly explain hospitalizations
(Required)
Been hospitalized?
(Required)
yes
no
Breifly explain any broken bones
(Required)
Been in an auto accident?
(Required)
yes
no
Breifly explain any auto accidents
(Required)
Had sprains/strains?
(Required)
yes
no
Breifly explain any sprains/strains
(Required)
Been struck unconscious?
(Required)
yes
no
Breifly explain being struck unconscious
(Required)
Had surgery?
(Required)
yes
no
Breifly explain any surgeries
(Required)
Family History
Please list any family members and any past or current health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.) If none, please enter none.
(Required)
Your Current Condition
Do you experience pain every day?
(Required)
yes
no
Do your symptoms interfere with daily life?
(Required)
yes
no
Does pain wake you up at night?
(Required)
yes
no
Are your symptoms worse during certain times of the day?
(Required)
yes
no
Do changes in weather affect your symptoms?
(Required)
yes
no
Do you wear orthotics?
(Required)
yes
no
Please list any activities that aggravate your symptoms:
Current Habits
Alcohol
(Required)
none
light
moderate
heavy
Coffee
(Required)
none
light
moderate
heavy
Tobacco
(Required)
none
light
moderate
heavy
Drugs
(Required)
none
light
moderate
heavy
Exercise
(Required)
none
light
moderate
heavy
Sleep
(Required)
none
light
moderate
heavy
Appetite
(Required)
none
light
moderate
heavy
Soft Drinks
(Required)
none
light
moderate
heavy
Water
(Required)
none
light
moderate
heavy
Salty Foods
(Required)
none
light
moderate
heavy
Sugary Foods
(Required)
none
light
moderate
heavy
Artificial Sweeteners
(Required)
none
light
moderate
heavy
Please check if you currently have or have a history of:
Alcoholism
Currently Have
Have a History of
Allergies
Currently Have
Have a History of
Anemia
Currently Have
Have a History of
Arteriosclerosis
Currently Have
Have a History of
Arthritis
Currently Have
Have a History of
Asthma
Currently Have
Have a History of
Back Pain
Currently Have
Have a History of
Breast lump
Currently Have
Have a History of
Bronchitis
Currently Have
Have a History of
Bruise Easily
Currently Have
Have a History of
Cancer
Currently Have
Have a History of
What type of cancer?
(Required)
Chest Pain/Conditions
Currently Have
Have a History of
Cold extremities
Currently Have
Have a History of
Constipation
Currently Have
Have a History of
Cramps
Currently Have
Have a History of
Depression
Currently Have
Have a History of
Diabetes
Currently Have
Have a History of
Digestion Problems
Currently Have
Have a History of
Dizziness
Currently Have
Have a History of
Ears Ring
Currently Have
Have a History of
Excessive Menstruation
Currently Have
Have a History of
Eye Pain/Difficulties
Currently Have
Have a History of
Fatigue
Currently Have
Have a History of
Frequent Urination
Currently Have
Have a History of
Headache
Currently Have
Have a History of
Hemorrhoids
Currently Have
Have a History of
High Blood Pressure
Currently Have
Have a History of
Hot Flashes
Currently Have
Have a History of
Irregular Heart Beat
Currently Have
Have a History of
Irregular Cycle
Currently Have
Have a History of
Kidney Infection
Currently Have
Have a History of
Kidney Stones
Currently Have
Have a History of
Loss of Balance
Currently Have
Have a History of
Loss of Memory
Currently Have
Have a History of
Loss of Smell
Currently Have
Have a History of
Loss of Taste
Currently Have
Have a History of
Morning Sickness
Currently Have
Have a History of
Neck Pain or Stiffness
Currently Have
Have a History of
Nervousness
Currently Have
Have a History of
Nosebleeds
Currently Have
Have a History of
Pacemaker
Currently Have
Have a History of
Polio
Currently Have
Have a History of
Poor Posture
Currently Have
Have a History of
Sciatica
Currently Have
Have a History of
Shortness of breath
Currently Have
Have a History of
Sinus Infection
Currently Have
Have a History of
Sleep problems/insomnia
Currently Have
Have a History of
Spinal Curvatures
Currently Have
Have a History of
Stroke
Currently Have
Have a History of
Swelling of ankles
Currently Have
Have a History of
Swollen Joints
Currently Have
Have a History of
Thyroid Condition
Currently Have
Have a History of
Ulcers
Currently Have
Have a History of
Varicose Veins
Currently Have
Have a History of
Venereal Disease
Currently Have
Have a History of
Other:
Currently Have
Have a History of
Please list any others
(Required)
Consent
(Required)
Please check this box confirm that you have read and filled out all the information above. Please note: If you cannot make your appointment, please notify us within 24 BUSINESS hours. There is a $20.00 fee for any cancellation or rescheduled appointments less than 24 BUSINESS hours before your scheduled time or missed appointments.
Signature
(Required)
Please use your mouse or finger to sign in this box.
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