Livewell | Pregnancy Screening Evaluation

Session*

General Client Details

Name*

Date of Birth*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Number*

Email*

GP Name and Address*

Obstetrician Name and Address*

Allocated Midwifes Name and Address (if known)

Estimated Date of Delivery*

Were you referred by a medical/health professional?*

Details of Health Professional:

Where did you hear about Live Well Waterford:*

Medical Questionnaire

Are you currently experiencing OR ever been diagnosed with any of the following conditions?

*

Is this your first pregnancy?*

If no, how many other children do you have and what are their ages?

Please note the AGE of each of your other children. Please also note the mode of delivery (vaginal or section) for each child, the weight at birth of each child, and report any previous obstetric injuries (tear/episiotomy) or any complications related to each delivery and pregnancy.

Did you have any complications with your previous pregnancy/pregnancies?*

How many weeks pregnant are you?*

Have you had any complications with your pregnancy?*

If yes, please specify*

Are you expecting a multiple birth?*

Are you currently experiencing pelvic girdle pain or spinal or hip pain?*

If yes, please explain:

Please describe where your pain complaints are. Be as accurate as possible, noting down whether the pain is sharp and shooting or dull, achy and muscular in nature. When did the pain start?

Is your condition getting worse?*

What activities aggravate your condition?*

What activities help your condition?*

Outline easing factors such as rest, ice, heat, certain positions, other therapies etc. Anything that has helped.

Is there a daily pattern to your condition?*

Are you best in the morning? Worst in the morning? Do things settle down with movement or get worse with movement? Please be as accurate as possible.

Did you exercise before pregnancy?*

If yes, briefly outline please:*

Have you been exercising during this pregnancy?*

If yes, please provide details:*

Which, if any, of the following conditions have you been diagnosed with or had treatment for:*

If other, please state:*

Current Health Status

Why have you decided to attend this LiveWell Pregnancy Service?*

What short and long term goals do have have from coming to this clinic?*

Please use this box if you feel there is any other information you would like to share with us prior to your appointment:

Thank you for taking the time to complete this form!

We really appreciate the time that you put in to completing this form. The information provided will very much help your clinican during your initial consultation. We rely on your feedback to help us improve our services. Your input is greatly appreciated.

Live Well Waterford

Pregnancy Screening Evaluation

Pregnancy Screening Evaluation

General Client Details

Medical Questionnaire

Current Health Status

Thank you for taking the time to complete this form!

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