Intake Form

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Name* This field is required
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example@example.com
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Address
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Country
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4
Phone Number* This field is required
Area Code
Phone Number
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5
Birthdate * This field is required
Date
Year
Month
Day
Date
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6
Profession
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7
Medications & Supplements * This field is required
Current Medications
Current Supplements
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8
Who may we thank for referring you?
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9
Choose Your Care* This field is requiredPlease select which type of care you are seeking
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10
How do you feel about your health in the category of SLEEP?
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11
How do you feel about your health in the category of NUTRITION?
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12
Are you on a special diet?If YES, please describe
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13
How do you feel about your health in the category of HYDRATION?
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14
How do you feel about your health in the category of EXERCISE?
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15
How do you feel about your health in the category of STRESS?
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16
Reason for Seeking Therapy* This field is required
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17
Reason for Seeking Therapy:
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18
Your Cycle
Frequency of Periods
Duration of Menses
Menarche (period onset)
Briefly describe your cycle (heavy, clots, pms, etc.)
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19
Date of Last Menstrual Period
Date
Year
Month
Day
Date
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20
Do you experience pelvic pain?Answer YES if you have a history of pelvic pain
YESNO
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21
Please describe the pain(ie. location, intensity, sensation, how it affects your daily activities and quality of life)
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22
When during your cycle do you experience pain?
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23
Have you received a medical diagnosis?
YESNO
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24
Please list the diagnosis and the method that was used:(ie. Type of testing, imaging, etc.)
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25
Gynecological History
History of birth control use
Current ultrasound results
History of sexual abuse
Pelvic/vaginal infections (and treatment)
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26
GI History
List any intestinal problems
Frequency of bowel movements?
Blood noted in BM?
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27
Have you had a positive pregnancy test before?
YESNO
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28
Obstetric History
Miscarriage? (dates of occurrences)
Elective abortion? (dates of occurrences)
Childbirth? (vaginal and/or C-section)
Birth trauma? (please describe)
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29
Have you gone through (or are you currently in) an IVF cycle?
YESNO
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30
History of IVF: (give dates and type of drug used, how many eggs retrieved, how many embryos transferred, outcome)
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31
Have you done (or are you planning to do) a medically assisted fertility cycle?
YESNO
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32
History of medically assisted fertility cycles: (dates, type of cycle, outcome)
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33
Have you had any of the following surgeries?
Gynecological surgery (OTHER than IVF or IUI)
Abdominal surgery
Urinary surgery
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34
Describe surgery dates and details:
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35
Thank you for taking the time to answer the questions regarding your upcoming Mercier Therapy appointment. During your visit the doctor will discuss your history with you, evaluate your general pelvic movement and check the position and mobility of your uterus and ovaries. From there, a plan for further care will be made if you are a candidate for Mercier Therapy.

We look forward to serving you!
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36
Basic Information
Age
Marital Status
Height
Weight
Number of hours at a desk
Repetitive Movements
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37
Reason for Seeking Chiropractic Care* This field is required(If there is more than one, please list them in order of importance)
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38
Have you been treated before for this problem?
YESNO
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39
What type of care did you receive?
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40
Concerning the primary issue, when did you first experience symptoms?
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41
What is your pain level today?Slide to describe how you are feeling today
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42
What is your pain level when it is most severe?
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43
What is your pain level on average?Slide to describe how you are feeling today
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44
Details about your condition
Symptoms occur suddenly or gradually?
Is it getting worse?
Local pain or does it radiate?
What worsens it? (ie. sitting, etc.)
Is it constant? How often?
What gives relief?
Describe your symptoms (sharp, achy, throbbing, dull, etc.)
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45
Does your condition interfere with any of the following?Check all that apply
Work
Sleep
Daily Routine
Recreation
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46
Have you had chiropractic care in the past?
YESNO
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47
What reason(s) did you receive care?
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48
Please list all surgeries and/or hospitalizations that you have undergone with reasons and corresponding dates:
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49
Please describe any serious accidents or injuries with corresponding dates (fractures, car accidents, sports injuries, falls, trauma):
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50
List the types and dates of any major illnesses:
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51
List any problems with PMS or your menstrual cycle:
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52
Do you feel like you have a strong pelvic floor? Why or why not?
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53
Do you experience any incontinence? If so, when?
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54
Do you experience any pelvic pain? If so, when?
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55
How many pregnancies have you carried?
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56
Have you ever had an episiotomy?
YESNO
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57
Have you ever had diastasis?
YESNO
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58
Do you have difficulty taking deep breaths?
YESNO
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59
Do you experience allergies? If so, which ones and when did they start?
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60
Please upload any images or files here:
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
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61
What are your health goals?Choose all that apply
More energy
Better concentration
Improved flexibility
Strengthening immune system
Easier breathing
Better sleep
Improved strength
Lessening stress
Less pain throughout the day
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62
Do you smoke?
YESNO
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63
Do you drink alcohol?
YESNO
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64
Do you drink caffeine?
YESNO
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65
Do you exercise?
YESNO
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66
What is your sleeping position?
Side
Back
Stomach
Toss & turn
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67
What are your hobbies?
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68
What do you do to relax?
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69
Use the space below to elaborate on your condition or give any information that may have been missed in the above questionnaire:
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70
Reason for Seeking Chiropractic Care* This field is required(If there is more than one, please list them in order of importance)
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71
Have you seen another practitioner for this condition?
YESNO
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72
Which kind of practitioner? Please describe the treatment.
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73
Is the problem:
Constant
Intermittent
Occasional
Cyclic
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74
How long has the problem persisted?
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75
When it is at its worst, how does it make your child feel?
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76
What have you done about it that has NOT worked?
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77
What makes it worse?
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78
What effect does this problem have on your child's bodily functions/daily activities?
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79
Describe any hospital stays:
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80
Medication
Present prescription drugs
Past prescription drugs
Rounds of antibiotics in the last 6 months?
Rounds of antibiotics in their lifetime?
Over the counter drugs (past 6 months)
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81
Were there any complications during the pregnancy?
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82
Was your baby full term?
YESNO
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83
Was your baby breech?
YESNO
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84
Where was your baby born?
Hospital
Home
Birth Center
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85
Labor Questions
Was labor induced?
Forceps/Vacuum delivery?
Length of labor?
Delivery complications?
Any pain meds during delivery (ie. epidural)?
C-section or VBAC? Planned?
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86
Signature
Clear
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87
Feeding Questions
Was baby breastfed?
How many months?
Issues with latch?
Preference of a side?
Arching back/neck?
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88
According to the National Safety Council, approximately 54% of infants fall head first from a high place (bed, changing table, etc.) during the first year of life. Has this happened to your child? Y/N? Comments.
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89
Please list any other falls or accidents
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90
Check any of the following conditions your child has suffered from (past or present):
Ear infections
Headaches
Chronic colds
Growing/back pains
Constipation
Scoliosis
Asthma/allergies
ADD/ADHD
Colic
Head banging
Seizures
Digestive problems
Recurring fevers
Bedwetting
Reaction to vaccination(s)
Sleeping problems
Did not gain weight
Autism
Learning difficulty
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91
Does your child participate in sports? If yes, please list
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92
Use the space below to elaborate on your condition or give any information that may have been missed in the above questionnaire:
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93
Please sign below:
Clear
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94
Thank you for taking the time to let us understand more about you, see you soon!
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