Full Circle Holistic- A Women’s Health-Care Practice 2110-B Bardstown Road Louisville, KY 40222 (502) 774-0460

The Arvigo Techniques of Maya Abdominal Therapy™ Confidential Intake

Date of Initial Visit______

Name:______

Address______

City ______State______Zip______Home Phone______

Work Phone______Cell______email______

Date of Birth______Age______Occupation______

Marital/Relationship status______Referred by______

Primary reason for visit:______

When did your first notice it?______What brought it on?______

Describe any stressors occurring at the time______

What activities provide relief?______what makes it worse?______

Is this condition getting worse?______interfere with work?______sleep?______recreation?______

Have you had massage/bodywork before?______What type?______

Are you currently under the care of another health care provider(s)?______Reason (s)______

______

Name(s) of Practitioner______Address:______

Phone______email______

Current Medications and /orSupplements/Remedies:______

______

Allergies: specify allergen and reaction:______

Surgical History (year and type) and/or Recent Procedures:______

______

Hospitalizations: ______

Accidents or Traumas______

Falls/Injuries to Sacrum/head/tailbone (describe)______

Please review and check the following:

Headaches
Type: / Past Present / Numbness in feet or legs when standing / Past Present
Asthma / Sore heels when walking
Cold Hands or
feet / Anxiety
Swollen ankles / Depression
Sinus Conditions
Frequent Colds / Sleep Disturbance
Seizures / Fainting Spells
Low Back Pain / Muscular Tension:
Location:
Skin Disorders:
Type / Varicose Veins
Hemorrhoids
Location
Sciatica / Herniated/Bulging Discs
Painful/Swollen
Joints / Artifical/Missing limbs
High or Low Blood
Pressure / Contact Lenses
Dentures/Partials / Cancer (past or current)
Type

Other:

Still Living? / Cause and Age of Death / Major Health Issues
Mother
Father
Siblings
Maternal
Grandmother
Maternal
Grandfather
Paternal
Grandfather
Paternal
Grandmother

Describe your typical:

Breakfast:______

Lunch:______

Dinner:______

Snacks:______Water Intake(glasses/day)______Caffeine______

What is the worst item in your diet______What foods are your weakness______

Are you subject to binge eating?______What foods______

Do you experience bloating/gas/burps after eating?______What foods trigger this?______

Food Allergies?______Describe______

How often are your bowel movements?______Do your stools: sink______float______

Constipation?______Blood in stool ?______Mucus in stool?______Pain when stooling?______

Diarrhea?______Other?______

What is your opinion of yourself?______

Describe the most positive emotion you experience______

When and Where do you experience this emotion?______

Describe the most negative emotion you experience______

When and Where do you experience this emotion?______

Describe your Spiritual and/or Religious practice:______

On a scale of 1 – 10 ( 1 being the lesser, 10 the greater) Please rate yourself in each of these qualities:

Faith______Hope____Charity____Generosity______Sense of Humor______Fear_____Grief_____Sense of Fun_____

What hobbies/ activities provide you with pleasure and accomplishment______

Describe your exercise routine (type, frequency)_______

What changes would you like to achieve in 6 months:______

One Year:______

Do you use Tobacco?______Quantity_____/ppd Alcohol?______Quantitiy______ounces/ day

Marijuana?______Quantity______Other:______Have you been under treatment for substance use?______

Method of Contraception (circle) pills patch diaphragm injection condoms IUD abstinence rhythm method

Fertility Awareness Other:______Length of time using method______Last Pap smear____Results _____

Are now or in the past experiencing Fertility Challenges? Yes___No___Describe your treatment :______

(IUI, IVF,etc)______

Menstrual History Review and check as indicated:

Age of Menses:______What was this like for you?______

Last Menstrual Period:______Length of Menses______

Are you trying to Conceive? Yes_____No______Are you Pregnant? Yes____No____Unsure____

Painful Periods / Past Present / Irregular cycles
Early Late / Past Present
Heaviness in Pelvis
prior to menses / Dark Thick Blood at:
Beginning
End
Both
Excessive Bleeding
Pads per Hour / Headache or Migraine
with menses
Dizziness / Bloating
Water Retention / Ovulation:
Painful
Failure to
Endometriosis
Location (if known) / Fibroids
Location (if known)
Uterine or Cervical
Polyps / Uterine Infection(s)
Vaginal Infection(s) / Cysts
Location:
Bladder Infection(s) / Urinary Incontinence
Painful Intercourse / Vaginal Dryness
Episodes of Amenorrhea
How long?

Rate your interest in Sex: High______Moderate______Low______None______

Do you have or ever had difficulty experiencing orgasms______

Have you experienced trauma? Yes___No____Describe______

Did you undergo counseling for this?______

What was this like for you?______

Pregnancy History

Number of Pregnancies:_____Dates______Miscarriage(s)______Dates______Termination(s)______Dates:______

Number of Births:______Dates:______

Complications for any of the above, describe:______

Premature Births?______Spotting During Pregnancy?_____Weak Newborns?______Incompetent Cervix? ______

Describe your experience with:

Pregnancy:______

Labor:______

Birthing: ______

Post Partum:______

Maternal Family History of (please circle) Infertility Fibroids Endometriosis PMS Menopause

Cancer(type)______Menstrual Problems ______Other______

Medications your mother took when she was pregnant with you (if any)______

Your Birth Trauma (if known) ______

Age symptoms began:______Are they getting worse______better______same______

Are you on/ or ever been on hormone replacement therapy?______if so, how long______

Name and dose______

Reason for stopping______

Age of Mother at menopause:______Concerns/Experience______

Check the following symptoms that apply to you:

Hot flashes / Insomnia / Fatigue / Memory Loss / Mood Swings
Vaginal Discharge / Dry Vagina / Depression / Anxiety / Irritability
Spotting / Flooding / Irregular Menses / Painful Intercourse / Increased Libido
Decreased Libido / Disturbed Sleep
Pattern

Additional Information you feel important your practitioner should know that is not mentioned here:

1

ATMAT Client IntakeFull Circle Holistic 11/2013