Maternal History Intake Form
Name and nickname: ___________________________________________________________________________
Date of Birth: ____________________
Gender:
Male
Female
Race: ________________
Address: _________________________________________________________________________
City:____________________________________State:_____Zip:____________
Phone Numbers-Home: _________________ Work: __________________ Cell: _______________
Preferred contact:
Home
Work
Cell E-mail:____________________________________
Date of Birth: ____________________
Marital Status:
M
S
W
D
Partner
Race: ________________ Ethnicity_____________________ Preferred Language___________
Occupation: _____________________________________________________________________
Employer: _______________________________________________________________________
Emergency Contact person: ________________________________________________________
Emergency contact phone number: __________________________________________________
How were you referred to our office: _________________________________________________
Primary Care Physician: ____________________________________________________________
INSURANCE INFORMATION
Please indicate any and all insurance coverage that may be applicable in this case.
Major Medical
Worker’s Comp
Medicare
Medicaid
Auto Accident
Name of primary insurance company _____________________________________________
AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all
information necessary to communicate with personal physicians and other healthcare providers and payers and to secure the payment of benefits. I understand
that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I will notify the chiropractic office of any change in my status in regards
to insurance information. I consent to the care including diagnostic procedures, examinations and treatment that the chiropractor designates and considers to
be necessary to treat my condition. The office may be reached by phone at 319-480-7492 and by fax at 888-243-0130.
The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare
operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning
those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we
encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. If there is anyone you do not want to receive your
medical records, please inform our office.
Patient signature: _______________________________________ Date: ____________________________
Guardian’s signature authorizing care: _________________________________Date: _______________
Larson Family Chiropractic, Laura J. Larson, DC, DICCP, 241 S. State St., Denver, IA 50622
Patient Name:________________________________________
Name of OB or Midwife: _________________________________________________________________
Date of Last Menstrual Period: _________________ Expected Due Date (EDD): ____________________
Chief Complaint:________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Previous Pregnancies/Children:
# of previous pregnancies: __________
Have you ever had any of the following:





Abortion
Stillbirth
C-section
Breech presentation
Multiple Births
# of Children: ____________ Ages: ______________






Tubal Pregnancy
Hemorrhaging
Pre-eclampsia
Diabetes
Thyroid Disease
Abnormal PAP Smear



High Blood Pressure
Use of Birth Control
Pills _____________
I.U.D. Use
What is your diet like? Any cravings?: ________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
How many glasses of water daily:________
Are you currently or have you during this pregnancy experienced any of the following?
 Spotting or
 Severe Morning

bleeding
Sickness

 Vomiting
 Neck pain

 Bladder Infection
 Hemorrhoids
 Heart Burn
 Varicose Veins

 Yeast Infection
 Low Back Pain

 Trauma __________________
Sciatica
Headaches
Midback or Rib
Pain
Numb Hands
Hip Pain
Have you had any laboratory testing? (ultrasounds, amniocentesis, chorionic villas sampling, etc…)
Which tests and what were the results? _______________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
What is your birth plan? (home, hospital, planned c-section, etc…)__________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Larson Family Chiropractic, Laura J. Larson, DC, DICCP, 240 S. State St., Denver, IA 50622
Patient Name:________________________________________
Circle “Y” for Yes or “N” for No to indicate if you have had any of the following:
AIDS/HIV
Y N Emphysema
Y N Miscarriage
Y N Suicide Attempt
Alcoholism
Y N Epilepsy
Y N Mononucleosis
Y N Thyroid
Problems
Allergy Shots
Y N Fractures
Y N Multiple Sclerosis Y N Tonsillitis
Anemia
Y N Glaucoma
Y N Mumps
Y N Tuberculosis
Anorexia
Y N Goiter
Y N Osteoporosis
Y N Tumors,
Growths
Appendicitis
Y N Gonorrhea
Y N Pacemaker
Y N Typhoid Fever
Arthritis
Y N Gout
Y N Parkinson’s
Y N Ulcers
Disease
Asthma
Y N Heart Disease
Y N Pinched Nerve
Y N Vaginal
Infections
Bleeding
Y N Hepatitis
Y N Pneumonia
Y N Venereal
Disorder
Disease
Breast Lumps
Y N Hernia
Y N Polio
Y N Whooping
Cough
Bronchitis
Y N Herniated Disk
Y N Prostate Problem
Y N Other:
Bulimia
Y N Herpes
Y N Prosthesis
Y N
Cancer
Y N High Cholesterol Y N Psychiatric Care
Y N
Cataracts
Y N Kidney Disease
Y N Rheumatoid
Y N
Arthritis
Chemical
Y N Liver Disease
Y N Rheumatic Fever
Y N
Dependency
Chicken Pox
Y N Measles
Y N Scarlet Fever
Y N
Diabetes
Y N Migraine
Y N Stroke
Y N
Headaches
EXERCISE
____None
____Moderate
____Daily
____Heavy
WORK ACTIVITY
____Sitting
____Standing
____Light Labor
____Heavy Labor
HABITS
____Smoking
____Alcohol
____Coffee/Caffeine Drinks
____Illegal Drugs
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Packs/Day ______
Drinks/Week ____
Cups/Daily _____
_______________
Injuries/Surgeries you have had
Description
Date
Falls ________________________________________________________________________________
Head Injuries ____________________________________________________________________________
Broken Bones ___________________________________________________________________________
Dislocations _____________________________________________________________________________
Surgeries _______________________________________________________________________________
Hospitalizations __________________________________________________________________________
Motor Vehicle Accidents __________________________________________________________________
Is there any other information that you would like to add?
_______________________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________________________________
QUADRUPLE VISUAL ANALOG SCALE
Please read carefully Please circle the number that best describes the question being asked.
Larson Family Chiropractic, Laura J. Larson, DC, DICCP, 240 S. State St., Denver, IA 50622
Patient Name:________________________________________
NOTE: If you have more than one complaint, please answer each question for each individual complaint and indicate the score
for each complaint. Please indicate you pain level right now, average pain and pain at its best and worst.
EXAMPLE:
headache
neck
low back
No pain ___________________________________________________________________________ worst possible pain
0
1
3
4
5
7
8
10
○2
○6
○9
What is your pain right now?
no pain ___________________________________________________________________________ worst possible pain
0
1
2
3
4
5
6
7
8
9
10
What is your typical or average pain?
no pain ___________________________________________________________________________ worst possible pain
0
1
2
3
4
5
6
7
8
9
10
What is your pain level at its best? (how close to “0” is your pain at its best)
no pain ___________________________________________________________________________ worst possible pain
0
1
2
3
4
5
6
7
8
9
10
What is your pain level at its worst? (how close to “10” is your pain at its worst)
no pain ___________________________________________________________________________ worst possible pain
0
1
2
3
4
5
6
7
8
9
10
Mark the areas on this body where you feel the described sensations. Use the appropriate symbols. Mark areas of radiation.
Include all affected areas.
Numbness
---------------
Pins & Needles
ooooooooooo
Burning
xxxxxxx
Aching
******
Stabbing
/////////
I verify that all information provided is true and complete to the best of my knowledge.
Signature:___________________________________________________Date:_____________________
Larson Family Chiropractic, Laura J. Larson, DC, DICCP, 240 S. State St., Denver, IA 50622