Fertility Massage Consultation Form Your details will be treated in confidence. * (required) Order Number Name * Email Address * Contact Number * Date of Birth Marital Status Reason for Visit/Primary Concern * When did this first occur? * Describe any stress that occurred at time of onset Is this condition interfering with Work Sleep Relationship Other Please, specify in case you chose Menstrual and Fertility Conditions PMS (Premestrual Syndrome) PMDD (Premenstrual Dysphoric Disorder) Painful Periods Painful Ovulation Irregular Periods Excessive Bleeding PCOS (Polycystic Ovary Syndrome) Fibroids Endometriosis Premature Ovarian Failure Failure to Ovulate Low AMH Miscarriage (once) Recurrent Miscarriage Symptoms experienced prior to and during menstruation Lower back ache Headaches Dizziness Breast Pain Change in bowels i.e. Constipation/Diarrhoea Painful/numbness in left leg Painful/numbness in right leg Dark thick blood at beginning of menstruation Dark thick blood at the end of menstruation Blood clots Cramps left side Cramps right side Cramps central lower abdomen Heaviness or pressure in lower pelvis Dragging sensation Increased Urination Symptoms currently experiencing Varicose veins left leg Varicose veins right leg Bladder infections Bladder weakness Frequent urination Difficulty experiencing orgasms Cold hands or feet Anxiety/Depression Trouble with sleep onset Trouble with sleep maintenance Tightness in chest Difficulty breathing into abdomen Uterine Prolapse Anal Prolapse Digestive Complaints Constipation (<1 per day) Diarrhoea IBS Crohn's disease Formed bowel movements (sausage like) Loose bowel movements Hard bowel movements Non-formed movements (pellets) Abdominal pain left side Abdominal pain right side Medical History Are you under treatment for infertility (i.e. IVF)? Have you had any surgery on your abdomen/lower back? Accidents or traumas? Falls or injuries to Sacrum, tailbone or head? Recent procedures (<6 months) High blood pressure Low blood pressure Other relevant medical conditions or anything you would like to specify or report Menstrual & Pregnancy History Age of menarche (first period) & experience * How many pregnancies have you had? * Number of deliveries? Dates of each birth Method of delivery Natural Water Birth Epidural/Pethidine Forceps/Ventouse C-section Terminations Miscarriage Ectopic If you have given birth, what was your experience of: Pregnancy Labour & Delivery Post Partum What are your feelings towards giving birth? Emotional and Spiritual What is your opinion of yourself? If possible, please describe the most negative emotion you experience When do you most often feel this emotion? Have you witnessed or experienced: Emotional abuse Physical abuse In childhood As an adult What changes would you like achieve in the next 6 months? What changes would you like to achieve in the next 12 months? Other Comments: Please use this space to give any further relevant information that you feel would be beneficial for me to know prior to your treatment Please advise here of any allergies, medication, medical conditions, operations within last 6 months or recent injuries Please read and tick to confirm: Cancellations within 48 hours will incur a 50% charge. Cancellations within 24 hours will incur a 100% charge. I understand the treatment is not a replacement for medical care. I understand that the therapist does not diagnose medical illness, disease or any other physical or mental conditions, prescribe medical treatment of pharmaceuticals, or perform any spinal manipulations. I have stated all known conditions and take it upon myself to keep the therapist updated on my health. You will be required to sign this consultation form at your appointment.