Let’s work togetherTeen Girl - Well Woman 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 know 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? What menstrual products do you use? 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 sexually active? Is there a possibility that you could currently be pregnant? Yes No Have you experienced sexual trauma? Do you have a history of STI's and/or vaginal infections? If known, how was your own birth? 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 Haemorrhoids Herniated/Bulging Discs Cancer *Past or Current Please describe further any of the symptoms you checked off above: 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!