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We Create Healthy Families

Call us at (605) 275-5757 to make an appointment.

Pregnancy

Pregnant Patient Intake Form







Female Male













Single
Married
Divorced
Widowed
Other






Existing Patient
Friend
Another Provider
Social Media
Radio Ad
Google Search


PREVIOUS BIRTH EXPERIENCE


Yes No




Yes No



CONCEPTION & EARLY PREGNANCY




Yes No




Yes No






Yes No



CURRENT HEALTH CONDITIONS




None 1-2x per week 3-6x per week Daily





Yes No




Yes No




Yes No



YOUR BIRTH PLAN







Yes No




Yes No






Yes No


Yes No




Yes No



YOUR POST-BIRTH PLAN

Yes No









CURRENT MUSCULOSKELETAL CONDITIONS





Yes No




Aching Sharp
Annoying Shock-like
Burning Shooting
Deep Stabbing
Diffuse Stiffness
Dull Throbbing
Heavy Tightness
Intolerable Tingling
Pulling OTHER


Gradual Insidious Recent Spontaneous Sudden Traumatic Unknown


Mild Mild to moderate Moderate Moderate to severe Severe


1 2 3 4 5 6 7 8 9 10

Least severe <------------------------------>Most severe


Constant Frequent Intermittent On and off Random Recurring


Improved Stayed the same Worsened


Employment
Homemaking
Social Life
Walking
Sitting
Standing
Sleeping
Lifting
Travelling or Driving
Personal Care





TRAUMAS:Physical Injury History




Yes No




Yes No




Yes No




Yes No




Back Side Stomach


Refreshed and ready Stiff and tired










Yes No




Yes No




Yes No




Yes No




Yes No

TOXINS: Chemical & Environmental Exposure

Please rate your CONSUMPTION for each where 0 is none and 5 is high:




0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5

THOUGHTS: Emotional Stresses & Challenges

Please rate your STRESS for each where 0 is none and 5 is high:




0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5


0 1 2 3 4 5

CHIROPRACTIC HISTORY


Yes No




Pain Relief Physical Therapy & Rehab Nutritional Subluxation-based Other

INSURANCE & PAYMENT FOR CARE


Personal Insurance No Insurance Self Pay

Primary Insurance











AUTHORIZATION

I certify that I'm the patient listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment at the time services are rendered.