The Sourcing CenterCONFIDENTIAL CLIENT INTAKE FORM - ABDOMINAL THERAPY
For: Assigned female at birth
Date of Initial Visit: ________________________________________________________________________________________
Name: ______________________________________________________________________________________________________
Preferred Pronoun: ________________________________________________________________________________________
DOB: ________________________________________________________________________________________________________
Age: _________________________________________________________________________________________________________
Occupation: ________________________________________________________________________________________________
Marital/Relationship Status: _____________________________________________________________________________
*Confidentiality of medical and personal information obtained during the course of the therapist’s work is of the utmost importance. HIPAA regulations require all practitioners obtain a signed release form from their client before taking any information about them. You can obtain a copy of this form you signed (upon request) and the therapist maintains a copy for their records.
CLIENT CONFIDENTIALITY + RELEASE FORM
I understand that this modality is not a replacement for medical care. The therapist does not diagnose medical illness, disease, or other physical or mental conditions. As such, the therapist does not prescribe medical treatment of pharmaceuticals, nor does she preform spinal manipulations. The therapist may recommend referral to a qualified health care professional for any physical or emotional conditions I may have. I have stated all my known conditions and take it upon myself to keep the therapist updated on my health.
I, (name) __________________________________________ give my permission, for my therapist, to take notes including health history, medical, and/or personal information I choose to disclose to her. I understand this information may be used in case studies of this technique for the purpose of statistical data collection only. All relevant identifying information will not be disclosed, such as name and date of birth.
Client Signature: _______________________________________________________________ Date:_____________________
Therapist Signature: __________________________________________________________ Date: _____________________
DISCLAIMER
*Consider this intake form as a step in your healing.
*Only answer what you can, what is relevant to you, and/or what you are comfortable with.
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: ___________________ E-mail: ___________________________
Current medications and/or supplements/remedies: _________________________________________________
Allergies (specify allergen + reaction): __________________________________________________________________
Surgical History (year + type) and/or recent procedures: _____________________________________________
Check the following symptoms that apply to you:
Past Present Past Present
Headaches + type Numbness in feet or legs while standing
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 Artificial, missing limbs
High or low blood pressure Contact lenses
Dentures, partials Cancer +type Other (not mentioned above):____________________________________________________________________________
Surgical history + recent procedures: ___________________________________________________________________
Hospitalizations: __________________________________________________________________________________________
Accidents or traumas: _____________________________________________________________________________________
Falls/injuries to sacrum/head/tailbone (describe): ___________________________________________________
Other: ______________________________________________________________________________________________________
REPRODCUTIVE HEALTH HISTORY
Method of contraception:
Pills
Patch
Diaphragm
Injection
Condoms
IUD
Abstinence
Rhythm method
Fertility awareness
Length of time using method: _________________________________________________________________________
Last pap smear: ____________________________________________________________________________________________
Results (if known): ________________________________________________________________________________________
Are you under treatment for infertility? Yes No
Describe treatment to date (IUI, IVF, etc.): ______________________________________________________________
Gynecological provider: ___________________________________________________________________________________
Address: _________________________________________________________________ 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
Check the following symptoms that apply to you:
Past Present Past Present
Painful periods Irregular cycles Early Late Heaviness in pelvis prior to menses Dark, thick blood at beginning end both Excessive bleeding pads/hour Headache, migraine with menses Dizziness Bloating Water retention Ovulation, painful or failure to Endometriosis location (if known) Vaginal dryness Uterine or cervical polyps Fibroids location (if known) Vaginal infection(s) Uterine infection(s) Bladder infection(s) Cysts + location Painful Intercourse. Urinary incontinence Episodes of amenorrhea, how long Tender breast with Ovulation Menses
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. Cancer, type_______________________ Menstrual problems
Other: ____________________________________________________________________________________________________
Your birth trauma (if known): ____________________________________________________________________________
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: rape trauma incest Did you undergo counseling for this? Yes No
Additional information: ___________________________________________________________________________________
MENOPAUSE
Age symptoms began: _________________ They are getting worse better 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 Flooding 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: ______________________
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
Which the most negative emotion you experience: _____________________________________________________
When do you most often feel this emotion? _____________________________________________________________
What hobbies/activities provide you with a sense of accomplishment? ______________________________
Describe your exercise routine (type, frequency): ______________________________________________________
Do you pray or have a spiritual practice? Yes No