Let’s work togetherDigestive & Reproductive Care Intake Form - Please Fill out at least 24 hours before your appointmentPlease fill to the best of your ability. Any information that you do not know or do not wish to disclose you can leave blank. Name * First Name Last Name Email * Phone * (###) ### #### What are you desires in receiving this care? If symptoms are apart of your reason for care, when did you first notice this and do you what brought it on? Describe any stressors correlated to this: What provides relief or aggravation for you? Have you received bodywork before? If so, what kinds? Are you currently under the care of any other healthcare providers? If so, please list reason for care: Do you have any allergies? If yes, please detail: Have you had any surgeries? If yes, please detail: Have you had any accidents or significant physical trauma? If yes, please detail: Have you had any falls and/or injuries to your sacrum/tailbone/head? If yes, please detail: Do you eat meat or other forms of animal foods? Have you experienced or are currently experiencing an eating disorder? If yes, please elaborate: Do you regularly consume or are you regularly exposed to any of the following? Alcohol Recreational Drugs Caffeine Tobacco Occupational Chemicals Mold Do you experience any of the following digestive symptoms on a regular basis? Excessive belching Excessive flatulence Binge Eating Acid Reflux Discomfort After Eating Constipation Diarrhea Mucus/Blood in Stool Food Allergies/Reactions Please describe your current movement/exercise routine: Please describe your current relationship to self, and any aspect of this that is in need of support: Are you currently on contraception? If yes, please detail: If you have a history of contraception, what methods have you used and for how long? Are you currently receiving any fertility treatment? If yes, please detail: Do you experience (past and/or presently) any of the following symptoms? Painful Periods Endometriosis Irregular Cycles Heaviness in Pelvis Prior to Menses Dark, thick blood at the beginning or end of cycle Excessive Bleeding Amenorrhea *absence of menstruation Headache/Migraine with Menses Painful Ovulation Lack of Ovulation Uterine/Cervical Polyps Cysts Fibroids Urinary Incontinence Vaginal Dryness Dizziness Water Retention Vaginal Infection Uterine Infection Bladder Infection Painful Intercourse Bloating If applicable, please describe your menstrual cycle - historically and currently, elaborating on any of the symptoms you checked off above: Are you currently trying to conceive? Yes No Is there a possibility that you could currently be pregnant? Yes No If applicable, please detail your reproductive history in terms of pregnancy and birth: If applicable, how was your experience of being pregnant and/or birthing? If known, how was your own birth? What is you relationship to sex? Do you have a history of STI's and/or vaginal infections? Have you experienced sexual trauma? If applicable and if you are willing, please elaborate as needed: Please check off any regularly occurring symptoms that apply to you: Headache/Migraine Asthma Cold Hands/Feet Sinus Conditions/Frequent Colds Seizures Swollen Ankles Low back Pain Skin Disorders Sciatica Painful/Swollen Joints High/Low Blood Pressure Numbness in Feet or Legs Anxiety Depression Sleep Disturbance Fainting Spells Muscular Tension Varicose Veins Haemorrhoids Herniated/Bulging Discs Cancer *Past or Current Please describe further any of the symptoms you checked off above: If applicable, describe your experience of menopause: If applicable, select any menopausal symptoms you have experienced: Irregular Menses Hot Flashes Vaginal Discharge Dry Vagina Spotting Decreased Libido Increased Libido Painful Intercourse Insomnia Disturbed Sleep Pattern Flooding Fatigue Mood Swings Irritability Anxiety Memory Loss Depression Do you have a history of cancer in your family? Is there anything else you wish to share that you feel it pertinent for our session together? Thank you!