Abdominal Therapy Form - Female at Birth

Only answer what you can, what is relevant to you, and what you are comfortable with sharing.


Date of Initial Visit: ________________________________________________________

Name: ________________________________________________________

Preferred Pronoun: ________________________________________________________

DOB: ________________________________________________________

Age: ________________________________________________________

Occupation: ________________________________________________________

Marital/Relationship Status: ________________________________________________________


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: ________________________________________________________

Current medications & supplements: ________________________________________________________

Allergies (specify allergen + reaction): ________________________________________________________

Surgical History: ________________________________________________________

Circle the following symptoms that apply to you:

Headaches + type PAST PRESENT
Numbness in feet or legs while standing PAST PRESENT
Asthma PAST PRESENT
Sore heels when walking PAST PRESENT

Cold hands or feet PAST PRESENT

Anxiety PAST PRESENT

Swollen ankles PAST PRESENT

Depression PAST PRESENT

Sinus conditions, frequent colds PAST PRESENT

Sleep disturbance PAST PRESENT

Seizures PAST PRESENT

Fainting spells PAST PRESENT

Low back pain PAST PRESENT

Muscular tension + location PAST PRESENT

Skin disorders + type PAST PRESENT

Varicose veins, hemorrhoids + location PAST PRESENT

Sciatica PAST PRESENT

Herniated/bulging discs PAST PRESENT

Painful, swollen joints PAST PRESENT

Artificial, missing limbs PAST PRESENT

High or low blood pressure PAST PRESENT

Contact lenses PAST PRESENT

Dentures, partials PAST PRESENT

Cancer +type PAST PRESENT

Other: ________________________________________________________


Surgical history + recent procedures: ________________________________________________________

Hospitalizations: ________________________________________________________

Accidents or traumas: ________________________________________________________

Falls/injuries to sacrum/head/tailbone: ________________________________________________________

Other: ________________________________________________________


REPRODCUTIVE HEALTH HISTORY


Circle Your Method of contraception:

Pills

Patch

Diaphragm

Injection

Condoms

IUD

Abstinence

Rhythm method

Fertility awareness

Length of time using method: ________________________________________________________

Last pap smear: ________________________________________________________

Results: ________________________________________________________

Are you under treatment for infertility? YES NO

Describe treatment to date (IUI, IVF, etc.): ________________________________________________________

Gynecological provider: ________________________________________________________

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


Circle the following symptoms that apply to you:

Painful periods PAST PRESENT

Irregular cycles EARLY LATE PAST PRESENT

Heaviness in pelvis prior to menses PAST PRESENT

Dark, thick blood BEGINING END PAST PRESENT

Excessive bleeding PADS/HOUR PAST PRESENT

Headache, migraine with menses PAST PRESENT

Dizziness PAST PRESENT

Bloating PAST PRESENT

Water Retention PAST PRESENT

Ovulation, painful or failure to PAST PRESENT

Endometriosis & location PAST PRESENT

Vaginal dryness PAST PRESENT

Uterine or cervical polyps PAST PRESENT

Fibroids & location PAST PRESENT

Vaginal infection(s) PAST PRESENT

Uterine infection(s) PAST PRESENT

Bladder infection(s) PAST PRESENT

Cysts & location PAST PRESENT

Painful Intercourse PAST PRESENT

Urinary incontinence PAST PRESENT

Episodes of amenorrhea & how long PAST PRESENT

Tender breast with OVULATION MENSES PAST PRESENT


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

MENSTRUAL PROBLEMS CANCER type ________________________________________________________

Other: ________________________________________________________

Your birth trauma: ________________________________________________________


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: TRAUMA RAPE INCEST

Did you undergo counseling for this? YES NO

Additional information: ________________________________________________________


MENOPAUSE


Age symptoms began: ________________________________________________________

They are getting BETTER WORSE 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

Fooding

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 quantity/day: ________________________________________________________

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


The most negative emotion you experience is: ________________________________________________________

When do you most often feel this emotion? ________________________________________________________

What hobbies/activities provide you with a sense of accomplishment? ______________________________

Describe your exercise routine: ________________________________________________________

Do you pray or have a spiritual practice? YES NO