Date of Initial Visit
Name
Address
Email Address
Contact number (m) / (h)
Date of Birth & Age / Marital Status
Ages of Children
Referred by:
Reason for visit
What is your primary concern?
When did it first occur?
Describe any stress occurring at the time of onset
Is this condition interfering with
Sleep?
Work?
Relationships?
Menstrual and Fertility Conditions
Painful Periods
Painful Ovulation
Irregular Periods
Excessive Bleeding (>1pad/tampon per/hr)
PCOS (Polycystic Ovarian Syndrome)
PCO (Polycystic ovaries)
Fibroids
Endometriosis
POF (Premature Ovarian Failure)
Failure to Ovulate
Low AMH
Miscarriage (once)
Recurrent Miscarriage
Symptoms experienced prior to and during menstruation
Lower back ache
Headaches
Dizziness
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
Digestive Complaints
Constipation (<1 per day)
Diarrhoea
IBS
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 / Details
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/low blood pressure
Other relevant medical conditions
Menstrual & Pregnancy History / Details
Age of menarche (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 & 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 do not complete this next section, this is for my records
Temperature
Section 1 / Cool
Warm / Damp
Hot
Section2 / Cool
Warm / Damp
Hot
Section 3 / Cool
Warm / Damp
Hot
Section 4 / Cool
Warm / Damp
Hot
Section 5 / Cool
Warm / Damp
Hot
Section 6 / Cool
Warm / Damp
Hot
Palpation
Section 1 / Tender
Bloated / Hard
Scar
Section2 / Tender
Bloated / Hard
Scar
Section 3 / Tender
Bloated / Hard
Scar
Section 4 / Tender
Bloated / Hard
Scar
Section 5 / Tender
Bloated / Hard
Scar
Section 6 / Tender
Bloated / Hard
Scar
Therapist Findings
Please read, confirm and sign
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 Clare Blake does not diagnose medical illness, disease or any other physical or mental conditions
As such the therapist does not prescribe medical treatment of pharmaceuticals, nor does she perform any spinal manipulations
I have stated all known conditions and take it upon myself to keep the therapist updated on my health.
Client Signature
Therapist signature
Thank you for taking the time to complete your consultation form.
Please return completed forms at least 7 days prior to your consultation date by email to
Clare Blake Fertility Massage Therapy 07713 477511