Prenatal Intake

Prenatal primary care physician's name and telephone number:

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What is your Expected Due Date?

Which trimester are you in?

How many previous pregnancies have you had?

Has you baby moved in the past 24 hours?

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Are you exercising during this pregnancy?

Yes

If yes, how often do you exercise per week, for what duration, and what types of exercise.

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Pregnancy specific medical questions. If the answer to any of the below is yes, please provide additional explanation in the comments section:

Abdominal Cramping

Pre-term labor

Chronic Hypertension

Leaking amniotic fluid

Bladder infection

Blood clot or phlebitis

Problems with placenta

Uterine bleeding

Other

Are you experiencing a high risk pregnancy?

Yes

If yes, please explain.

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Please describe this pregnancy in your own words.

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Have you ever had professional massage?

Yes

Are you wearing contact lenses?

Yes

Do you sit for long periods of time such as at a desk or in car driving?

Yes

If yes, please explain:

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Have you ever had surgery?

Yes

If yes, please explain:

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Do you have any allergies and/or food sensitivities (including topical and seasonal):

Yes

If yes, please explain:

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Do you have any other medical conditions that I should be aware of?

Yes

If yes, please explain:

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What are the characteristics of your pain?

Achy

Throbbing

Tender

Radiating

Stabbing

Tingling

Numbness

Spasms

Headaches

Joint stiffness/swelling

Spasms/cramps

Broken/fractured bones

Strains/sprains

Back, hip pain

Shoulder, neck, arm, hand pain

Leg, foot pain

Chest, ribs, abdominal pain

Problems walking

Jaw pain

Tendinitis

Bursitis

Arthritis

Osteoporosis

Scoliosis

Bone or joint disease

Other

Dizziness

Shortness of breath o Fainting

Cold feet or hands o Cold sweats

Swollen ankles

Pressure sores

Varicose veins

Blood clots

Stroke

Heart condition

Allergies

Sinus problems

Asthma

High blood pressure

Low blood pressure

Lymphedema

Other

Rashes

Allergies

Athlete's Foot

Warts

Moles

Acne

Psoriasis

Cosmetic surgery

Other

Nervous stomach

Indigestion o Constipation

Intestinal gas/bloating

Diarrhea

Diverticulitis

Irritable bowel syndrome

Crohn's Disease

Colitis

Adaptive aids

Other

Numbness/tingling o Twitching of face o Fatigue

o Chronic pain

Sleep disorders

Ulcers

Paralysis

Herpes/shingles

Cerebral Palsy

Epilepsy

Chronic Fatigue Syndrome

Multiple Sclerosis

Muscular Dystrophy

Parkinson's disease

Spinal cord injury

Other

PMS

Menopause

Pelvic Inflammatory Disease

Endometriosis

Hysterectomy

Fertility concerns

Other

Loss of appetite

Forgetfulness

Confusion

Depression

Difficulty concentrating

Drug use

Alcohol use

Nicotine use

Caffeine use

Hearing impaired

Visually impaired

Burning upon urination

Bladder infection

Eating disorder

Diabetes

Fibromyalgia

Post/Polio Syndrome

Cancer

Surgeries

Infectious disease (please list)

Other congenital or acquired disabilities (please list)

Other

Please list any additional comments regarding your health and well-being:

I have stated all conditions that I am aware of and this information is true and accurate. I will inform the health care provider of any changes in my status.

Doctor’s/Midwife consent needed.

Cardiac, Pulmonary, Renal or Liver Disorder

Drug or Hazardous Material Exposure

Premature Labor

Diabetes

Maternal Illness (Lupus), Epilepsy, Structural issues, etc.

Mother took DES during pregnancy

Gestational Diabetes

None

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