Medical QuestionnairePlease fill in the questionnaire to the best of your knowledge. Fields marked * are required. Personal detailsFirst name *Last name *Email *Phone *Week of pregnancy *Age *Estimated due date *Number of previous births * Reason for treatmentWhat is the reason (or reasons) you came for treatment? * Additional complaintsMark any additional complaints, if relevant Lower back pain Upper back / shoulder blade pain Pelvic pain Tailbone pain Pain when walking / limping Buttock pain Pain radiating to the leg Abdominal pain / pressure Lower abdominal pain Hard / tight belly Difficulty breathing Heartburn Increased fatigue Difficulty sleeping / falling asleep Pain when changing position Pressure on the bladder Constipation Swelling (edema) Symphysiolysis (SPD)Suspected symphysiolysis (SPD)? If so, please answer the following questions Yes NoWho diagnosed it?Where is the pain?In which week did the pain start?Symphysiolysis in previous pregnancies?Are you being treated? If so, where and by whom? Breech positionBreech position? If so, please answer the following questions Yes NoSince which week has the baby been breech?Was the baby head-down at any point? If so, in which week?Breech baby in previous pregnancies?Specific breech position (frank, footling or complete)Was an external cephalic version (ECV) attempted? If so, when? Other treatmentsHave you tried or had other treatments during this pregnancy? Moxa Chiropractic Homeopathy Heat or cold Acupressure points Acupuncture Osteopathy / craniosacral therapy Inversion table MassageOther treatment? Medical backgroundMark whatever is relevant Pregnancy bed rest Previous caesarean section Breech Anterior placenta / placenta previa / placenta accreta High-risk pregnancy Risk of preterm birth Bicornuate uterus Diastasis recti Previous injuries Twins Miscarriages Vaginal bleeding Glaucoma Headaches Dizziness High blood pressure Physical work Sports activity Varicose veins Early contractions Birth before week 37 Waters breaking before week 37Is there any other medical matter I should know about? Surgeries (including laparoscopy, cosmetic, medical) Patient declarationI am aware that I am receiving pelvic and uterine balancing treatment from a certified Equilibrio practitioner. I am also aware that the treatment I receive does not replace any other medical treatment, and that any change to recommendations given by a doctor will be made in coordination with them, including taking medication, follow-up tests or any other recommendation. Digital signature *Clear signature I agree to the collection and storage of the health information I have provided, for tailoring and providing treatment, as described in the Privacy Policy. * Please click once and wait for the confirmation that the form was sent.Send
