Only answer what you can, what is relevant to you, and what you are comfortable with sharing.
Date of Initial Visit: ________________________________________________________
Name: ________________________________________________________
Preferred Pronoun: ________________________________________________________
DOB: ________________________________________________________
Age: ________________________________________________________
Occupation: ________________________________________________________
Marital/Relationship Status: ________________________________________________________
REASON FOR VISIT
Primary reason for visit: ________________________________________________________
When did you first notice it? ________________________________________________________
What brought it on? ________________________________________________________
Describe any stressors occurring at the time: ________________________________________________________
What activities provide relief? ________________________________________________________
Is this condition getting worse? YES NO
What makes it worse? ________________________________________________________
Interferes with WORK SLEEP RECREATION
Have you had massage therapy before? YES NO
What type? ________________________________________________________
FAMILY HISTORY
Still living? Cause of death/age of Major health issues
Mother YES NO ________________________________________________________
Father YES NO ________________________________________________________
Sibling(s) YES NO ________________________________________________________
Maternal Grandmother YES NO ________________________________________________________
Maternal Grandfather YES NO ________________________________________________________
Paternal Grandmother YES NO ________________________________________________________
Paternal Grandfather YES NO ________________________________________________________
MEDICAL HISTORY
Are you currently under the care of another health care provider(s)? YES NO
Reason(s): ________________________________________________________
Name(s) of practitioner: ________________________________________________________
Address: ________________________________________________________
Phone: ________________________________________________________
Current medications & supplements: ________________________________________________________
Allergies (specify allergen + reaction): ________________________________________________________
Surgical History: ________________________________________________________
Circle the following symptoms that apply to you:
Headaches + type PAST PRESENT
Numbness in feet or legs while standing PAST PRESENT
Asthma PAST PRESENT
Sore heels when walking PAST PRESENT
Cold hands or feet PAST PRESENT
Anxiety PAST PRESENT
Swollen ankles PAST PRESENT
Depression PAST PRESENT
Sinus conditions, frequent colds PAST PRESENT
Sleep disturbance PAST PRESENT
Seizures PAST PRESENT
Fainting spells PAST PRESENT
Low back pain PAST PRESENT
Muscular tension + location PAST PRESENT
Skin disorders + type PAST PRESENT
Varicose veins, hemorrhoids + location PAST PRESENT
Sciatica PAST PRESENT
Herniated/bulging discs PAST PRESENT
Painful, swollen joints PAST PRESENT
Artificial, missing limbs PAST PRESENT
High or low blood pressure PAST PRESENT
Contact lenses PAST PRESENT
Dentures, partials PAST PRESENT
Cancer +type PAST PRESENT
Other: ________________________________________________________
Surgical history + recent procedures: ________________________________________________________
Hospitalizations: ________________________________________________________
Accidents or traumas: ________________________________________________________
Falls/injuries to sacrum/head/tailbone: ________________________________________________________
Other: ________________________________________________________
REPRODCUTIVE HEALTH HISTORY
Circle Your Method of contraception:
Pills
Patch
Diaphragm
Injection
Condoms
IUD
Abstinence
Rhythm method
Fertility awareness
Length of time using method: ________________________________________________________
Last pap smear: ________________________________________________________
Results: ________________________________________________________
Are you under treatment for infertility? YES NO
Describe treatment to date (IUI, IVF, etc.): ________________________________________________________
Gynecological provider: ________________________________________________________
Phone: ________________________________________________________
Age of menses: ________________________________________________________
What was this like for you? ________________________________________________________
Last menstrual period: ________________________________________________________
Length of menses: ________________________________________________________
Does your menses have an odor? YES NO
Are you currently menstruating? YES NO
Are you trying to conceive? YES NO
Possibility of pregnancy? YES NO
Circle the following symptoms that apply to you:
Painful periods PAST PRESENT
Irregular cycles EARLY LATE PAST PRESENT
Heaviness in pelvis prior to menses PAST PRESENT
Dark, thick blood BEGINING END PAST PRESENT
Excessive bleeding PADS/HOUR PAST PRESENT
Headache, migraine with menses PAST PRESENT
Dizziness PAST PRESENT
Bloating PAST PRESENT
Water Retention PAST PRESENT
Ovulation, painful or failure to PAST PRESENT
Endometriosis & location PAST PRESENT
Vaginal dryness PAST PRESENT
Uterine or cervical polyps PAST PRESENT
Fibroids & location PAST PRESENT
Vaginal infection(s) PAST PRESENT
Uterine infection(s) PAST PRESENT
Bladder infection(s) PAST PRESENT
Cysts & location PAST PRESENT
Painful Intercourse PAST PRESENT
Urinary incontinence PAST PRESENT
Episodes of amenorrhea & how long PAST PRESENT
Tender breast with OVULATION MENSES PAST PRESENT
PREGNANCY HISTORY
Number of pregnancies: ________________________________________________________
Miscarriages: ________________________________________________________
Terminations: ________________________________________________________
Number of births: ________________________________________________________
Dates: ________________________________________________________
Complications: ________________________________________________________
Premature births ________________________________________________________
Incompetent cervix? YES NO
Spotting during pregnancy? YES NO
Weak newborns at birth? YES NO
Briefly describe your experience with:
Pregnancy: ________________________________________________________
Labor: ________________________________________________________
Birthing: ________________________________________________________
Post-partum: ________________________________________________________
Do you have Diastasis Recti? YES NO
Are you less than 6 weeks post vaginal birth? YES NO
Are you less than 3 months post caesarean birth?YES NO
Maternal family history of: INFERTILITY FIBROIDS ENDOMETRIOSIS PMS MENOPAUSE
MENSTRUAL PROBLEMS CANCER type ________________________________________________________
Other: ________________________________________________________
Your birth trauma: ________________________________________________________
SEX
Rate you interest in Sex: HIGH MODERATE LOW NONE
Do you ever or ever had difficulty experiencing orgasms? YES NO
Do you have history of: TRAUMA RAPE INCEST
Did you undergo counseling for this? YES NO
Additional information: ________________________________________________________
MENOPAUSE
Age symptoms began: ________________________________________________________
They are getting BETTER WORSE SAME
Are you on or ever been on hormone replacement therapy? YES NO
If so, how long? ________________________________________________________
Name + dose: ________________________________________________________
Reason for stopping: ________________________________________________________
Age of mother at menopause: ________________________________________________________
Concerns/experience: ________________________________________________________
Check the following symptoms that apply to you:
Hot flashes
Insomnia
Fatigue
Mood swings
Vaginal discharge
Dry vagina
Depression
Irritability
Spotting
Fooding
Irregular menses
Painful intercourse
Increased libido
Decreased libido
Disturbed sleep pattern
Memory loss
Anxiety
Additional information: ________________________________________________________
DIGESTION + ELIMINATION
Glasses of water/day: ________________________________________________________
Cups of caffeine/day: ________________________________________________________
Tobacco quantity/day: ________________________________________________________
Marijuana quantity/day: ________________________________________________________
Other quantity/day: ________________________________________________________
Have you been under treatment for substance abuse? YES NO
Are you subject to binge eating? YES NO
What foods? ________________________________________________________
Do you experience bloating/gas/burps after eating? YES NO
What foods trigger this? ________________________________________________________
How often are your bowel movements? ________________________________________________________
Constipation? YES NO
Blood in stool? YES NO
Mucus in stool? YES NO
Pain when stooling? YES NO
Other concerns: ________________________________________________________
EMOTIONAL + SPIRITUAL
The most negative emotion you experience is: ________________________________________________________
When do you most often feel this emotion? ________________________________________________________
What hobbies/activities provide you with a sense of accomplishment? ______________________________
Describe your exercise routine: ________________________________________________________
Do you pray or have a spiritual practice? YES NO
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