Pregnancy Health History
Why This Form Is Important
Our focus is on assisting clients to function optimally, for them to become more self aware, stronger, healthier and for improved adaptation to everyday stresses.
Completion of this form provides us with an improved understanding of your physical, emotional and chemical stresses that can gradually overwhelm the body over time and contribute to health problems. Please complete this form as thoroughly as possible and the doctor will review it with you.
Information on this form is strictly confidential and will not be shared without your consent.
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Name
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Your answer
Age
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Your answer
Birth date
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Email
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Your answer
Address
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Your answer
City
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Your answer
State
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Your answer
Zip Code
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Your answer
Country
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Your answer
Phone Number
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Your answer
Marital Status
Your answer
Occupation
Your answer
Family Doctor and Contact Information
Your answer
Who may we thank for referring you?
Your answer
#1. Current Health Concern
If there are no current concerns and this assessment is to ensure optimum health, function and wellness check this box.
Your answer
Describe health concern.
Your answer
#2. About Your Pregnancy
Is this your first pregnancy?
Yes
No
Clear selection
If this is not your first, how many times have you been pregnant?
Your answer
Have you had any complications with previous pregnancies? (If yes, please explain)
Your answer
If you have had a miscarriage, how far along in your pregnancy did it occur?
Your answer
Was this pregnancy planned?
Yes
No
Clear selection
What is the estimated date of delivery?
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Who is your primary care giver for delivery? ObGyn/GP/Midwife? Name?
Your answer
What/where is your planned location for delivery? Hospital/Home/Birthing clinic/Other?
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Your answer
How do you feel about this pregnancy?
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Your answer
Do you have a birth plan?
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Yes
No
Would you like information on creating a birth plan?
Yes
No
Clear selection
Any special arrangements for the birth? Planned C-sec/Water Delivery/Birth Chair/Squat/Other?
Your answer
Would you like additional information on options for birth posturing?
Yes
No
Clear selection
Have you had any testing? Genetic, blood, ultrasound, amniocentesis, chorionic villisampling, other? Dates and reasons:
Your answer
Are you planning on breastfeeding post delivery?
Yes
No
Clear selection
Would you like further information on the advantages of breastfeeding?
Yes
No
Clear selection
Was your blood pressure prior to pregnancy within normal range, low or high?
Your answer
What is your present blood pressure and when was it last checked?
Your answer
Would you like further information on healthy nutrition for pregnancy?
Yes
No
Clear selection
Have you changed your diet/menu since learning of your pregnancy?
Yes
No
Clear selection
Have you smoked prior to or along with this pregnancy?
Yes
No
Clear selection
Have you had alcohol during this pregnancy?
Yes
No
Clear selection
Have you noticed any of the following?
Swelling in the arms or legs
Lower back pain
Upper back pain
Neck pain
Rib or chest pain
Any foot pain
Digestive complaints (Heartburn, constipation)
Nausea or vomiting
Arm or hand numbness/tingling
Dizziness or lightheadedness
Headaches
Pain radiating down the leg(s)
Heart palpitations
When or how often?
Your answer
If pain from anything noted above is involved, rank it on a scale of 1 to 10 (1 is minimal, 10 is extreme)
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10
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Describe it’s character (sharp, dull, ache, burning, tingling, throbbing, spasms, other)
Your answer
When did you notice it and what happened?
Your answer
What relieves it?
Your answer
What aggravates it?
Your answer
Does it radiate or cause problems elsewhere?
Your answer
Any associated or related concerns?
Your answer
Professionals seen for this? (name)
Your answer
Treatment and results
Your answer
Please note all other health concerns present or in the past.Please include any of the following that apply:
Allergies
Stuffy nose
Runny sinuses
Frequent colds
Lowered immune resistance
Loss of Balance
Difficulty concentrating
Fatigue
Indigestion
Bloating
Appendicitis
Asthma
Bronchitis
Emphysema
Pneumonia
Bleeding disorders
Cancer
Cataracts
Vision changes
Diabetes
Hypoglycemia
Epilepsy
Heart Disease
Hypertension
Migraines
Hepatitis
High cholesterol
Difficult digestion
Loose stools
Hernia
Herniated Disc
Kidney Disease
Liver disease
Multiple Sclerosis
Osteoarthritis
Rheumatoid arthritis
Osteoporosis
Parkinson’s Disease
Thyroid problem
Tonsillitis
Ulcers
Urinary tract infections
Ulcerative colitis
Any other concerns you would like to include?
Your answer
#3. Physical Stresses
Any significant injuries, falls or traumas during infancy or childhood? (Yes/No/Unsure)If yes, please explain
Your answer
Any significant injuries, falls or traumas (for example, car accidents) during adulthood? (Yes/No/Unsure)If yes, please explain
Your answer
Any hospital visits? Please explain
Your answer
Have you had any surgeries or fractures? (Yes/No)If yes, please explain and include dates.
Your answer
Are you in prolonged postures (ex: repetitive work, lifting, sitting, driving)? (Yes/No/Unsure)If yes, please explain
Your answer
Any hobbies that are physically strenuous or have repetitive movements? (Yes/No/Unsure)If yes, please explain
Your answer
What is your usual exercise routine?
Your answer
Any fractured bones or dislocations?
Your answer
Any vehicle accidents? What happened and when?
Your answer
#4. Chemical Stresses
Are you currently taking prescription or over-the-counter medications? (Yes/No)If yes, please indicate what you are taking and why
Your answer
Are you currently taking supplements? (Yes/No)If yes, please indicate what you are taking and why
Your answer
Do you drink bottled water?
Yes
No
Occasionally
Clear selection
Are you exposed to pollutants, strong smells, chemicals, aerosols?
Yes
No
Occasionally
Clear selection
Do you eat organic?
Yes
No
Occasionally
Clear selection
Do you use natural or environmentally friendly products in your home? I.E. Cleaning supplies, hair and makeup, etc.
Yes
No
Occasionally
Clear selection
Do you drink or bathe/shower in chlorinated water?
Yes
No
Occasionally
Clear selection
#5 Mental/Emotional Stresses
Since psychological stress has been shown to affect numerous systems and fetal function, please let us know how you are coping with life’s stresses.
Rank from 1 to 10 with 1 being minimal to 10 being extreme)
Life in general... I feel
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Work and Career I feel
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Relationships I feel
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Financial stress I feel
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Time management I feel
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Sports and Hobbies I feel
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Today's Date
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