Download Pregnancy Paperwork - NuVista Chiropractic and Wellness

250-462-4776
#166-290 Riverside Dr.
Penticton, BC, V2Y 5Y5
www.nuvistachiropractic.com
INTAKE FORM
Name:
Birthdate:
Address:
Name
Phone: (home)
Birthdate
(month/day/year) (cell)
Address
Email:
Postal Code:
Occupation:
How did you hear about us? ☐ Friend:
☐ Other professional:
Extended Benefits Provider:
Care Card #:
(month / day / yea
I would like: ☐ email reminders
Postal Code
☐ text message reminders
☐ phone call reminders
How did you hear about our clinic? □Friend:
□Yellow Pages
□Sign □Website
☐ Website
☐ Facebook□Other:
Do ☐
you
currently wear orthotics? □Yes □No
Other:
Are you interested in gait analysis?
ICBC or WCB Claim? ☐ Yes ☐ No
□Yes □No
Claim #:
CURRENT CONDITION:
CURRENT CONDITION:
Please de
What brings you into the office today?
How long
When did it start?
Have you
What mak
Is it getting?: ☐ Better ☐ Worse
Have you had this before?: ☐ Yes ☐ No
When?
What mak
W
List any other professionals seen for this:
Does this
Wor
When do your symptoms affect you the most?
Are you currently taking any medication or supplements?: Please list:
Do you have any allergies?:
What are your goals for treatment?:
CURRENT PREGNANCY:
How far along are you in your pregnancy? !
Due Date?
Have you experienced issues with fertility or miscarriage? ☐ Yes ☐ No
Childbirth caregivers (circle):
OB/GYN
Last visit with caregiver:
Midwife
Doula:
Any concerns?:
Are you planning on having your baby: ☐ In hospital ☐ At home ☐ Other:
Are you currently taking any medication or supplements?: Please list:
Have you ever, or have you currently experienced any of the following during
pregnancy?:
☐falls/trauma
seizures
☐ MVA
☐ high blood pressure
☐ heart problems
☐ diabetes
☐ back/hip/groin pain
☐ hospitalizations ☐ trouble sleeping
☐ anemia
☐
☐ abnormal bleeding
☐ headaches/neck pains
☐ any other illness or concerns (describe):
Are you currently exercising or doing any other activities?:
Are you currently working?:
PREVIOUS PREGNANCIES:
How many pregnancies have you previously had?:
p: 250.448.8008
f: 250.448.7428
Did you experience any complications during the delivery?:
565 Osprey Avenue Any emergency care needed?
Kelowna, BC V1Y 5A7
www.kelowna-chiro.com
HEALTH HISTORY AND INFORMATION:
PERSONAL
HEALTH
HISTORY
-that
The
following
a variety Please
of conditions
Y - The following
lists
a variety
of conditions
that
patients
experience.
read that patients m
Please
check
any
conditions/symptoms
apply
tomay
you:lists
through
the that
list and
check
x next to each
condition
applies
to the
you.box next to each condition that applies to you.
GENERAL CURRENT
CONDITIONS
DIAGNOSED
CONDTIONS
DIAGNOSED
CONDTIONS
SPECIFIC
PAIN
IN THE BODY
□ Difficulty swallowing because of neck
□ pain
Born with bone or joint disorder
□
Osteoporosis
□ Pain
or electric shocks in arms or legs
□ when
Degenerative
arthritis/Osteoarthritis
moving neck
□
Rheumatoid
arthritis
□ Leg pain worse with exercise
Compression fracture
□□ Numbness
of inner thighs
□
Heart attack or heart disorder
□□ Back
pain with urinary problems
History of stroke or aneurysm
□□ Severe
pain that interrupts sleep
Cancer
□□ Constant
pain that doesn’t improve by
Diabetes
changing positions or by lying down
□ Gout
□ Lupus
□ Ankylosing
spondylitis
SPECIFIC
CURRENT
CONDITIONS
□ Immune suppression treatment or
disorder
from chemotherapy, organ
□ Poor
balance
transplant,
etc.
□ Loss of boweldrug,
or bladder
control
□
3
or
more
steroid
□ Blurred or doublemonths
vision, of
dizziness,
SPE
□
Recent
accident
as a fall,
□ □ Born
with bone
or joint such
disorder
whiplash,
or
blow
to
the
head
□
□ Osteoporosis
Spinal/back/neck
problems
□ □ Degenerative
arthritis/Osteoarthritis
Muscle spasms
□
□ □ Rheumatoid
arthritis
□
Restricted movement
□
□ Compression
fracture
Numbness
orheart
tingling
of hands or feet
□
eet
□ □ Heart
attack or
disorder
or radiating
pain
□
□ History
of stroke
or aneurysm
□
Headaches
or
Migraines
□
□ Cancer
□
Sinus
problems
□ Diabetes
Nausea
□ □ Gout
□
Depression
□ Lupus
Anxiety orspondylitis
difficulty with stress
SPE
□ □ Ankylosing
□
Dizziness
or
vertigo
□ Immune suppression treatment or
□
□ disorder
Vision problem
from chemotherapy, organ
□
□ transplant,
Hearing problem
drug, etc.
□
Sleeping trouble
□□
3 or more months of steroid
medications
or intravenous
drugsis(past
□ medications
Asthma or breathing problem
nausea
or faintness
when neck
in
or intravenous drugs (past
□ or Digestive
trouble
or
present)
certain positions
present)
□
Heartburn/Acid Reflux
Tuberculosis
□□ Memory
loss after injury
□□
Tuberculosis
□
Menstrual problems
Hepatitis
B or HIV infection
□□ Recent,
unexplained
weight loss
□□
Hepatitis B or HIV infection
□
Jaw or mouth problem
Multipleprogressive
sclerosis muscle weakness
□□ Recent
□□
Multiple sclerosis
Arm, shoulder, elbow or hand problem
□ orThyroid
shakingor hormone disorder
em
□□
Thyroid or hormone disorder
□
□
Leg, hip, knee or foot problem
□
High
pressure
□ Recentblood
or current
fever over 102°F
□ High blood pressure
□ Convulsions/epilepsy
□ Convulsions/epilepsy
□ OTHER:
□ OTHER:
Describe
anybeen
surgeries
/ hospitalizations
/ motor vehicle
accidents / sporting accidents / pe
Have
you ever
diagnosed
with a accidents
medical condition?
(describe)
alizations / motor
vehicle
accidents
/ sporting
/ personal/work
accidents /
fractures / dislocations / & / or illnesses you’ve had and the dates:
nesses you’ve had and the dates:
fall,
Please describe any serious trauma/ accidents/ injuries/ surgeries/ hospitalizations?
Please list any Medications you presently take AND what condition you are taking th
u presently take AND what condition you are taking them for: Have you ever had any other health
concerns?
(describe):
Have you had chiropractic care before: ☐ Yes ☐ No
Current supplements and Why you are taking them:
you are taking them:
Are you exercising or performing any physical activities?
Known Allergies (including medications, foods, seasonal, oils and lotions, etc.)
dications, foods, seasonal, oils and lotions, etc.)
________________________________________________________________________
______________________________________________________________________
YOUR LIFESTYLE
How would you describe your sleep habits?
How would you describe your diet?
Any other concerns or issues we should be aware of?:
Please Note: Your appointment time has been reserved for you. In courtesy of your therapist and fellow
patients, we ask that you provide us with 12 hours notice of cancellation, or a cancellation fee will be
charged. Payment for all treatment, whether private or insured, is ultimately the responsibility of the
patient.
I authorize the clinic and its associated practitioners to collect my personal and medical information as
documented above in order to contact me, and I give the clinic permission to leave messages regarding
appointments at any of the contacts I have provided above. In addition, I authorize the clinic and its
associated practitioners to communicate with my referring MD as deemed necessary for my benificial
treatment. I also understand that my personal and medical information is confidential and will only be
disclosed to third parties with my permission.
Signature:
Date: