Holistic Pelvic Care Intake formPlease fill out this form to the best of your ability prior to your appointment! Name * First Name Last Name Date of your appointment * MM DD YYYY Email * Would you like to be added to our email list to receive future updates, promotions, discounts, and details about community events? * Yes, please! No thanks! I am already on it! How did you hear about us? * What is your gender and what are your preferred pronouns? * What is your occupation? * What is your date of birth? * Is your session a mobile session or an office session? * Mobile Office If this is a mobile bodywork session, what is the address where the session will be held? Address 1 Address 2 City State/Province Zip/Postal Code Country Primary care provider name Primary care provider phone number Do you have any skin sensitivities of scent sensitivities of any kind? If so, please specify. * Have you received professional bodywork in the past? If so, what modalities have you received, and have your experiences been enjoyable? * Please tell me about your chief concern(s): (describe the concern(s), when did it start, is it constant or does it come and go, what helps it, what aggravates it, was there a specific incident which caused it, Pain – type, intensity, frequency, etc.) * What would you like to achieve in terms of your health and wellness? * Are you currently contagious with anything that might impact a bodywork session? * Please check any area in the checkboxes below that might apply to you currently or in the past: * Low Back Pain Menstrual Pain/PMS Pain During Sex Fibroids/Cysts Hemorrhoids Tearing With Birth Sexual Abuse Depression Drug Abuse Eating Disorder Pelvic/Abdominal Pain Prolonged Bleeding/Altered Cycles Sexually Transmitted Diseases UTI/Bladder Infection Constipation/Irritable Bowel Childbirth Complications Physical/Other Abuse Cancer Smoking Habit Other Relevant Info None Please describe any of the areas that you have checked above that apply to the PAST or PRESENT. Please provide dates if possible. * Date Of Last Pelvic Exam/PAP: Results: Any Past Positive PAP? * Yes No Please list any pelvic or abdominal surgeries: Please list the types of birth control that have been used in the past and present and the length of time they were each used for. Are you currently pregnant? Yes No If yes, how many weeks? If postpartum, how many months? Are you experiencing/have you experienced any complications in your pregnancy? If yes, please describe. Please list the number of pregnancies that you have had in the past, and the delivery types of each Have you had any recent life changes ? If yes, please describe. * How would you best describe your current lifestyle? * Please briefly describe your relationship with your womb. * Is there anything else about your health history that you think would be helpful for your bodywork practitioner to know to plan a safe and effective treatment for you? *
