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 *
Age *
Birth date *
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Email *
Address *
City *
State *
Zip Code *
Country *
Phone Number *
Marital Status
Occupation
Family Doctor and Contact Information
Who may we thank for referring you?
#1. Current Health Concern
If there are no current concerns and this assessment is to ensure optimum health, function and wellness check this box.
Describe health concern.
#2. About Your Pregnancy
Is this your first pregnancy?
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If this is not your first, how many times have you been pregnant?
Have you had any complications with previous pregnancies? (If yes, please explain)
If you have had a miscarriage, how far along in your pregnancy did it occur?
Was this pregnancy planned?
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What is the estimated date of delivery?
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Who is your primary care giver for delivery? ObGyn/GP/Midwife? Name?
What/where is your planned location for delivery? Hospital/Home/Birthing clinic/Other? *
How do you feel about this pregnancy? *
Do you have a birth plan? *
Would you like information on creating a birth plan?
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Any special arrangements for the birth? Planned C-sec/Water Delivery/Birth Chair/Squat/Other?
Would you like additional information on options for birth posturing?
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Have you had any testing? Genetic, blood, ultrasound, amniocentesis, chorionic villisampling, other? Dates and reasons:
Are you planning on breastfeeding post delivery?
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Would you like further information on the advantages of breastfeeding?
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Was your blood pressure prior to pregnancy within normal range, low or high?
What is your present blood pressure and when was it last checked?
Would you like further information on healthy nutrition for pregnancy?
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Have you changed your diet/menu since learning of your pregnancy?
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Have you smoked prior to or along with this pregnancy?
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Have you had alcohol during this pregnancy?
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Have you noticed any of the following?
When or how often?
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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Describe it’s character (sharp, dull, ache, burning, tingling, throbbing, spasms, other)
When did you notice it and what happened?
What relieves it?
What aggravates it?
Does it radiate or cause problems elsewhere?
Any associated or related concerns?
Professionals seen for this? (name)
Treatment and results
Please note all other health concerns present or in the past.Please include any of the following that apply:
Any other concerns you would like to include?
#3. Physical Stresses
Any significant injuries, falls or traumas during infancy or childhood? (Yes/No/Unsure)If yes, please explain
Any significant injuries, falls or traumas (for example, car accidents) during adulthood? (Yes/No/Unsure)If yes, please explain
Any hospital visits? Please explain
Have you had any surgeries or fractures? (Yes/No)If yes, please explain and include dates.
Are you in prolonged postures (ex: repetitive work, lifting, sitting, driving)? (Yes/No/Unsure)If yes, please explain
Any hobbies that are physically strenuous or have repetitive movements? (Yes/No/Unsure)If yes, please explain
What is your usual exercise routine?
Any fractured bones or dislocations?
Any vehicle accidents? What happened and when?
#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
Are you currently taking supplements? (Yes/No)If yes, please indicate what you are taking and why
Do you drink bottled water?
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Are you exposed to pollutants, strong smells, chemicals, aerosols?
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Do you eat organic?
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Do you use natural or environmentally friendly products in your home? I.E. Cleaning supplies, hair and makeup, etc.
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Do you drink or bathe/shower in chlorinated water?
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#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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