Prenatal Intake Form
Welcome to VIM Chiropractic and The Centered Stone. We look forward to meeting you and thank you for the opportunity to serve you in your chiropractic needs. Please fill out this history so that we may look over it before your appointment allowing your appointment to go more smoothly. These details allow us to better serve you.
Name *
Email *
Address *
Phone number *
Height
Weight
Marital Status
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Name of spouse
Number children
Employer
Occupation
Are you seeking care for a work related injury or automobile accident injury?  
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Who can we thank for referring you to our office?
Who is your primary care physician? OBGYN /Midwife?
Have you ever been to a Chiropractor before?
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If you've been to a Chiropractor before, when was your last appointment?
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If you've been to a Chiropractor before, what is the name of your previous Chiropractor, and reason for discontinuing care with them?
Reason for seeking chiropractic care?
What are your expectations?
Do you have any known allergies?
Have you ever been treated on an emergency basis or sustained an injury such as a fall or auto accident?
Review of health history: please indicate whether you have ever experienced any of the following now or previously:
current within last 6 months
Past 6+ months previously:
allergies
anxiety
arthritis
broken bones
colds/flu
constipation
convulsions/ seizures
D&C
depression
digestive problems
diarrhea
earaches
eating disorder
Fibromyalgia
headaches
heart conditions
infections
Inflammatory / Autoimmune condition
Miscarriage
muscle spasms
osteoporosis
paralysis
poor appetite
Rheumatoid Arthritis
scoliosis
skin/rash
sleeping problems
Thyroid
torticollis
Unexplained weight gain
Unexplained weight loss
How often do you exercise, and what type of exercise do you typically do?
Please list any other medical conditions you have been diagnosed with.
Please indicated any medications (prescription or non-prescription) you are currently taking.
Family history: Please check if any blood relatives to the child had any of the following (under other please indicate which relative):
Does anyone in the home smoke?
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Do you have any other concerns or problems that you would like to address? If so, please explain:
Are you currently pregnant?
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What is your expected due date?
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DD
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YYYY
Where do you plan to deliver?
Number of prior pregnancies?
Have you experienced complications in prior pregnancies or during delivery? If so , please explain.
Are you experiencing any of the following?
Is there anything else you'd like to bring up or you think I should know about?
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