Abdominal Therapy Form - Male 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:

Condoms

IUD

Abstinence

Rhythm method

Fertility awareness

Length of time using method: ________________________________________________________


Circle the following symptoms that apply to you:

Painful urination PAST PRESENT

Difficulty starting or holding urine stream PAST PRESENT

Urinary incontinence or dribbling PAST PRESENT

Blood or pus in urine PAST PRESENT

Weak or interrupted urine flow PAST PRESENT

Pelvic pressure PAST PRESENT

Pain or burning with urination PAST PRESENT

Instable sex drive PAST PRESENT

Nocturnal urination, how often? PAST PRESENT

Pain/discomfort between scrotum & testicles PAST PRESENT

Pain in lower back, especially after intercourse PAST PRESENT

Pain/discomfort in inner thighs RIGHT LEFT

Pain Discomfort in PENIS TESTICLES RECTUM PAST PRESENT

Difficulty in obtaining maintaining erection PAST PRESENT

Frequent bladder or kidney infections, when? PAST PRESENT

Urinary retention PAST PRESENT

Painful ejaculation PAST PRESENT


Results of PSA (prostate specific antigen) test: ________________________________________________________

Date done: ________________________________________________________

Results of sperm count: ________________________________________________________

Date done: ________________________________________________________

Family history of prostate disease? YES NO

Relationship: ________________________________________________________

Family History of cancer? YES NO

Relationship: ________________________________________________________


SEX


Sexually transmitted disease? YES NO

Type: ________________________________________________________

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: ________________________________________________________


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