Pregnancy Pre-Therapy Health & Lifestyle Questionnaire
Client Name:
DOB: Client Address: Client Phone No: Client Email: |
Due Date/No. Of Weeks Pregnant:
Health Care Provider Details:
|
First Impressions/Visual Assessment
|
|
Reason for seeking therapy today? Where do you have pain/discomfort? (Use Body Map Diagram).
|
Any excessive or sudden swelling and water retention? |
History of miscarriages? |
Any history or blood clots or Thrombosis? Any extreme calf pain, swelling or redness? |
Last visit to Primary Health Provider and outcome? Scan results?
|
Any severe and chronic itching (globally) ? |
Extreme high blood pressure – current and previous history?
|
Any excessive thirst and urination? Gestational or Controlled Type 1 or 2 Diabetes? |
Any rapid or large weight gain while Pregnant?
|
Any varicose veins or haemorrhoids? |
Any Varicose Veins? |
Current multiple pregnancy?
|
Any Bleeding During Pregnancy? |
Any skin rashes, open or unhealed cuts or bruises?
|
Any Headaches, Blurred Vision, Vomiting today or recently?
|
Any previous/recent illnesses or injuries or hospitalization? |
Any Symphysis Pubis Dysfunction or other Pelvic Pain?
|
Any strange/worrying physical symptoms during your pregnancy recently or previously? |
Notes/Treatment Plan & Session Outcome/Follow-Up
|
www.burrelleducation.com – Passionate About Pregnancy & Post Natal Health & Fitness Education FOREVER!
Visit the SITE and FACEBOOK PAGE for lots of FREE STUFF, COURSES & ‘THE CRUNCHLESS CORE DVD’.
Leave a comment