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Oaktree New Patient Pregnancy Chiropractic Forms

Patient Information

Patient Name*
Date of Birth*
What is your preferred method of communication?
Marital Status*
How did you hear about Oaktree Health?
I consent to receiving email communication from Oaktree *
(Emails we will send you include news updates from Oaktree. We will not spam you and you can unsubscribe at anytime. You will still receive appointment reminders and other important notices via email)

Chiropractic History

Have you been to a Chiropractor before?*
Were x-rays taken?
Approximate date of last visit:

Pregnancy Related Questions

Have you ever given birth before?
If yes, was it:
Was this pregnancy the result of IVF?
Prior to this pregnancy, did you have any miscarriages?
Where do you plan to give birth?
Complications during pregnancy:
Ultrasounds during pregnancy:
Medications during pregnancy
Vaccines during pregnancy
Cigarette/alcohol use during pregnancy:

Primary Health Concern

Is your condition getting progressively worse?*

Secondary Health Concern (if applicable)

Is your condition getting progressively worse?

Conditions and Symptoms

Cardiovascular System
Respiratory System
Digestive system
Musculoskeletal system
General symptoms
Females only
What health concerns (if any) are you experiencing during your pregnancy?

Previous Traumas

From heights, down stairs, other falls, broken bones, childhood falls, other injuries, etc.
Posture and Habits
Participation in high impact activities:
Birth Trauma - Was your birth:
1= Poor, 10 = Excellent
1= Not committed as all, 10 = Highly committed

Disease Causation Analysis

Exercise - How often do you stretch per week?
Exercise - How often do you participate in aerobic exercise?
Emotional Stress - Are you currently experiencing stress in the following areas?
Parents and siblings
Please specify type: coil, foam, rubber, etc.
Equipment - Pillow
Equipment - Do you wear:
Chemical Stresses - Do you feel that you make healthy food choices?
Chemical Stresses - Are you at your ideal body weight?
Example: Omega 3, Vitamin B, Probiotics, Vitamin D, Multivitamin, Iron
Chemical Stresses - Do you presently:
Chemical Stresses - Do you consume alcohol? If so how often:

Medical History Health Conditions

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