What is your full name? *As it appears on your ID, Insurance card or medical record
What is your email address? *We'll use this to keep you up to date with office news and announcements
What is your phone number? *Please enter the best available phone number to reach you.
What is your complete home address? *Street number, City, State, and Zip Code
What is your date of birth?
What is your age?
Due Date
Week of preganancy you are in
Pre-pregnancy weight
Current weight
Height
Childbirth preparation
Childbirth caregiver typeOBGYNDoulaMidwife
Caregiver's name
Caregiver's phone number
Last visit to caregiver
I plan on giving birth at HospitalHomeBirth Center
What position do you sleep in?
Any traumas during this pregnancy? YesNo
If yes, please describe
Any hospitalizations during this pregnancy? YesNo
Any medications during this pregnancy, including over the counter medication? YesNo
Any fertility treatment? YesNo
Any other information you would like us to know about you and your pregnancy?
Number of previous pregnancies
Number of previous births
Please explain any difference in numbers
Names and ages of children
Your previous births were at
Name of Hospital or Birth Center
Medications used in prior births
Interventions used in prior births
How long was your previous labor?
Total hours
Time before you pushed
Time you spent pushing
Did you have chiropractic care during your previous pregnancies? YesNo
Position of baby Head downPosterior/Sunny side upBreechMalposition
Position Confirmation
Confirmed by palpation by
Confirmed by ultrasound by
Confirmation date
How long do you believe baby has been in this position?
International Chiropractic Pediatric Association definition of Webster Technique: The Webster technique is a specific chiropractic analysis and adjustment that reduces interference to the nervous system, balances out pelvic muscles and ligaments which in turn removes torsion to the uterus, reducing the potential for intrauterine constraint and allows the baby to get into the best possible position for birth.
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