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PREGNANCY HEALTH HISTORY QUESTIONNAIRE Welcome to our office All questions in this questionnaire are strictly confidential and will become part of your record.

Title:

Dr

Full Name:

Mr

Mrs

Ms

Miss

Today’s date: __________________________

_________________________________ Preferred Name:____________________

Marital Status: Single

Partnered Married

Separated

Divorced

Widowed

Spouse / Partner’s name: _________________________________________________________ Date of birth: _____________________ Number of children:_______ Ages:______________ Address:_______________________________________________________________________ Suburb:____________________________________________ Postcode:___________________ Home phone: ____________________________ Work phone: ___________________________ Mobile phone:___________________________ E mail address: _________________________ Occupation: _____________________________Employer:______________________________ Have you had chiropractic care before? Yes No If yes, where did you go? _________________________________________________________ When was your last visit there? ____________________________________________________ Who may we thank for referring you to our clinic? ____________________________________

PERSONAL HEALTH HISTORY How many weeks pregnant are you?__________ How many pregnancies have you had?_______ If this is a subsequent pregnancy and birth for you, how do you feel about your previous birth experience/s?

Delighted

Neutral

Disheartened

Comment _____________________

___________________________________________________________________________________ Who are you receiving your prenatal care from?__________________________________________ What type of birth are you planning?

Hospital

Birthing centre

Home birth

What clinical tests have you had to date?________________________________________________


Any ultrasounds?____________________________________________________________________ Are you aware of the current position of your baby?______________________________________ Do you currently have any health issues? YES NO (If yes please explain) ___________________________________________________________________________________ ___________________________________________________________________________________ If you are experiencing any complaints, please describe and mark on the diagram below:

Describe any trauma/accidents you have had: __________________________________________ Describe any surgeries you have had: _________________________________________________ List any medications/ supplements you take or have taken:________________________________ __________________________________________________________________________________ OTHER SYMPTOMS YOU HAVE OR HAVE HAD IN THE PAST (please circle) Dizziness

Tension

Ringing in ears

Headaches

Neck pain

Digestion problems

Allergies

Menstrual pain

Fainting

Sleeping problems

Fever/infections

Fatigue

Nervousness

Chest pain

Depression

Pre eclampsia

Gestational diabetes

High blood pressure

Eclampsia

Placental issues

Abnormal bleeding

Low blood pressure

Swollen ankles

Anaemia

Signature: __________________________________________ Date: ________________

Pregnancy health history  
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