CONFIDENTIAL 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