Pregnancy Intake Questionnaire

Patient Name: *

Date *

PREVIOUS BIRTH EXPERIENCE

Is this your first pregnancy?

Yes

If no, please tell us about your previous pregnancy and / or birth experience(s):

Do you plan to follow the same plan as your previous delivery? *

Yes

If not, what would you like to change?

CONCEPTIONS & EARLY PREGNANCY

When is your expected calculated due date? *

Did you have any difficulty conceiving? *

Yes

If yes, please explain:

Have you ever used any form of hormonal or oral contraceptives? *

Yes

If yes, which ones, and how long?

When was your last menstrual cycle? *

What was your pre-pregnancy weight? *

Current weight? *

Have you experienced morning sickness? *

Yes

If yes, please explain:

CURRENT HEALTH CONDITIONS

What type of exercise(s) are you currently performing? *

Please tell us about your current diet, and any dietary restrictions.

Have you taken any medications or supplements during pregnancy? *

Yes

If yes, please explain:

Have you had any slips, falls, or other physical traumas during the pregnancy? *

Yes

If yes, please explain:

Have you had any major emotional stressors during your pregnancy? *

Yes

If yes, please explain:

YOUR BIRTH PLAN

What are your top three goals for this pregnancy?

Goal #1: *

Goal #2:

Goal #3:

Do you currently have a birth plan? *

Yes

If yes, please explain:

Are you taking any prenatal or birthing classes? *

Yes

If yes, please explain:

Who is your OB / GYN or midwife? *

Will they be present for delivery? *

Yes

Who is your birth provider?

Do you intend to have a doula or birth coach present? *

Yes

If yes, please explain:

Do you wish to have a natural vaginal labor and delivery? *

Yes

If not, what concerns do you have?

YOUR POST BIRTH PLAN

Do you plan on breastfeeding your child? *

Yes

What do you intend to do for vaccines? *

Is there anything else you'd like to tell us about your pregnancy or birth plan? *

What would you like to gain from chiropractic care during your pregnancy?

Are there any burning questions that you want to be sure to ask today?

Office Hours

Sunday: 9:30a - 1:30p

Monday: 9:00a - 12:00p, 1:00p - 3:00p, 4:00p - 6:30p

Tuesday: 9:00a - 11:00a

Wednesday: 9:00a - 1:00p, 3:00p - 6:00p

Thursday: 1:30p - 3:00p. 4:00p - 7:30p

Friday: 9:00a - 1:30p

Contact Info

3178 Bathurst Street

Email: [email protected]

Telephone: (416) 782-1462

3178 Bathurst St, North York, ON M6A 2A9, Canada