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Your Health Story

Please fill out the questionnaire below to the best of your ability. Some of the questions may feel challenging to answer or may seem unrelated to your primary issue. The goal of this health story is to look at you and your life experiences holistically, compassionately and as a tool for education. 


Date Signed: December 26, 2024

Your Health Story | © Abdominal Therapy Collective | March 2023

First Participant's Name

First Name*

Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Preferred pronoun

Gender currently identifying as

Gender assigned at birth

How did you hear about me and this work?

Abdominal Therapy is not a substitute for care by your medical doctor. Abdominal Therapy practitioners do not diagnose medical diseases, physical or mental conditions. Abdominal Therapy practitioners do not prescribe medical pharmaceuticals. 

COVID-19 Information

Have you had Covid-19?*
No
Yes

If so, when?
Are you vaccinated against Covid-19?*
No
Yes
Do you have any complaints in connection with the vaccination or the infection?*
No
Yes

If yes, can you describe these side effects?

I have stated all known conditions and will keep my practitioner updated on my health. By signing below, I confirm all the information I’ve provided is correct. I understand this information will remain confidential. 

What’s the reason for your visit?


Primary reason for this visit?

What would you like to achieve as a result of your visit?

When did you first notice this?

Do you feel something may have triggered this?

Describe any stressors occurring at this time?

What makes you feel better?

What makes you feel worse?

What changes or goals would you like to achieve over the next 3/6 months?

A Little bit of History


Are you taking any of the following – medication, supplementation, natural remedies? If so, please give details:

Do you use alcohol or recreational drugs? If so, how regularly and how do you feel about this?

Do you smoke? If so, how regularly and how do you feel about this?

Any allergies? If yes, what are you allergic to? What reaction do you have?

Have you experienced any of the following? If so, please share some details.


Surgery

Accidents

Injuries to sacrum/head/tailbone

Concerns

Do you, or have you ever suffered from any of the following:
Headache
Asthma
Cold hands/feet
Swollen ankles
Sinus conditions/colds
Seizures
Skin conditions
Lower back pain
Sciatica
Herniated/bulging discs
Painful/swollen joints
Neck/shoulder/jaw tension
High/low blood pressure
Sore heels when walking
Anxiety
Depression
Sleep disturbance
Feeling faint
Varicose veins
Cancer (type)
Haemorrhoids
Numb feet on standing

Family Story

Please share any significant details of your birth family story if known; this may include physical or mental health, lifestyle, cause/age of death of your parents and any other details you feel are relevant.


Maternal

Paternal

Gut Health


Describe your relationship with food?

What were mealtimes like growing up?

What are mealtimes like now?

Do you have any food intolerances or allergies?

Do you follow a particular diet?

Click to customize text box label
Do you eat home cooked food?*

What is your typical daily intake of the following? 


Water

Caffeine

Alcohol
Do you experience any bloating, burbs or flatulence after eating?*
No
Yes

If so, what triggers this?

How often are your bowel movements?

Do you suffer from abdominal pain, constipation, diarrhea, incomplete bowel movements, thin stools, blood or mucus in your stools?

Mental & Emotional Health


How do you nurture yourself?

Where and how do you find joy?

Are you currently experiencing stress?

How do these affect your life and how do you manage them?

Do you have a faith or spiritual practice and if so, would you be willing to share this?

What exercise do you enjoy, and how often do you do it?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Have you experienced any traumatic events that you would be willing to share?

Have you considered seeking professional support?

Pelvic Health

Do you experience pelvic pain or congestion?*
No
Yes

If so, how does this affect you?
Do you experience pain in any of the following areas?
Uterus
Ovaries
Vagina
Vulva
Penis
Prostate
Testicles
Rectum
Pain during sex
Perineum
Do you experience any of the following urinary issues? If so, how does this affect you?
Incontinence – coughing, jumping
Overactive bladder
Night time urgency
Cystitis
Incomplete bladder emptying
Constant leakage
Interstitial Cystitis
Kidney Stones
Bladder cancer
Bladder prolapse
Bladder stones

Have you had any pelvic tests – PAP, PSA or STD?
Have you ever had abnormal results?*
No
Yes

If so when, and did you receive treatment?
Do you currently/have you use/used birth control? *
No
Yes
If so, please indicate which one:
Pill
Patch
Diaphragm
Injection
Condoms
IUD
Abstinence
Rhythm Method
Fertility Awareness Method

If hormonal, how long for:

Menstrual Health

Do you experience any of the following:
Painful periods
Absent period
Lower back pain before/during/after bleeding
Irregular cycles
Heaviness prior to period
Dark thick blood -start/end
Excessive bleeding
Clots
Dizziness
Bowel changes
Headache/migraine
Water retention
Endometriosis
Painful ovulation
Irregular ovulation
Lack of ovulation
Vaginal dryness
Bleeding/spotting during ovulation
Premature Ovarian Failure
Polyps - uterine/cervical
Fibroids - location/size/number
Cysts - location/size/number
Incontinence- bladder/bowel
Bloating

If Fibroids - please provide location/size/number

If Cysts - please provide location/size/number

How old were you when you started menstruating?

What was this like for you?

How many days is your menstrual cycle?

How many days is your bleed? Please include number of days spotting at beginning or end.

What menstrual products do you use?

Do you bleed through more than one tampon or pad per hour?

When was your last menstrual bleed?

How do you feel about your menstrual cycle?

Do you chart your cycle?

If so how – App, paper charts?
Do you know if your mother, sister or other close female relations have experienced any of the following issues?
Infertility
Fibroids
Endometriosis
Cancer
Menstrual issues
Menopause issues

Urogenital Health

Do you experience or have a history of any of the following:
Painful/burning on urination
Urinary retention
Frequent bladder infections
Blood/pus in urine
Pelvic pain/pressure
Night time urination
Changes in sex drive
Cystitis
Interstitial cystitis
Prostate disease or cancer
Urinary incontinence or dribbling
Difficult to start urination
Weak/interrupted urine flow
Pelvic injury or surgery
Sperm related fertility issues
Vulvodynia
Herpes
HPV
Bartholomew Cysts
Do you experience or have a history of pain/discomfort in:
Testicles
Penis
Rectum
Inner Thigh
Pelvic Floor/perineum
Erection pain/problems
Lower back pain especially after sex

Desire & Libido


Do you enjoy making love?

Do you climax?

Are you satisfied with your level of sexual desire?

Have you noticed any changes recently?

How do you feel about this?

Fertility & Pregnancy Health 


Are you hoping to conceive?

If so, how long have you been trying?
Have you or your partner had any pregnancies?*
No
Yes

If so, did you choose to continue with them and what were they like?

Have you experienced any loss?

Have you given or witnessed birth?

If so, what was the experience like?

How was your postpartum experience?

Have you had any fertility tests e.g. Sperm or egg reserve?

Are you under the care of a fertility specialist?

Please describe any treatment you may have received including - IUI, IVF, ICSI, Hormone treatment or Surgery.

Peri/Menopause Health


How do you feel about your menopausal journey?

What stories do you carry?

What positive menopausal role models do you have?

Are you keeping your menopausal journal?
Do you experience any of the following:
Hot flushes
Vaginal discharge
Increased libido
Decreased libido
Painful sex
Insomnia
Dry/itchy skin
Dry/itchy vagina
Vaginal Atrophy
Spotting
Flooding
Tiredness
Depression
Anxiety
Irregular menses
Poor memory
Mood swings
Irritability

When did you start to notice symptoms?

Are these changing, increasing or decreasing?
Have you noticed a connection between your symptoms and:
Diet
Work Load
Stress levels

Do you use, or have you ever used hormone replacement therapy or bio-identical hormones?

If so, which ones, and for how long?

Thank you for taking the time to share your information. 


Is there anything else you would like to tell me?
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Preferred pronoun

Gender currently identifying as

Gender assigned at birth

How did you hear about me and this work?

Abdominal Therapy is not a substitute for care by your medical doctor. Abdominal Therapy practitioners do not diagnose medical diseases, physical or mental conditions. Abdominal Therapy practitioners do not prescribe medical pharmaceuticals. 

COVID-19 Information

Have you had Covid-19?*
No
Yes

If so, when?
Are you vaccinated against Covid-19?*
No
Yes
Do you have any complaints in connection with the vaccination or the infection?*
No
Yes

If yes, can you describe these side effects?

I have stated all known conditions and will keep my practitioner updated on my health. By signing below, I confirm all the information I’ve provided is correct. I understand this information will remain confidential. 

What’s the reason for your visit?


Primary reason for this visit?

What would you like to achieve as a result of your visit?

When did you first notice this?

Do you feel something may have triggered this?

Describe any stressors occurring at this time?

What makes you feel better?

What makes you feel worse?

What changes or goals would you like to achieve over the next 3/6 months?

A Little bit of History


Are you taking any of the following – medication, supplementation, natural remedies? If so, please give details:

Do you use alcohol or recreational drugs? If so, how regularly and how do you feel about this?

Do you smoke? If so, how regularly and how do you feel about this?

Any allergies? If yes, what are you allergic to? What reaction do you have?

Have you experienced any of the following? If so, please share some details.


Surgery

Accidents

Injuries to sacrum/head/tailbone

Concerns

Do you, or have you ever suffered from any of the following:
Headache
Asthma
Cold hands/feet
Swollen ankles
Sinus conditions/colds
Seizures
Skin conditions
Lower back pain
Sciatica
Herniated/bulging discs
Painful/swollen joints
Neck/shoulder/jaw tension
High/low blood pressure
Sore heels when walking
Anxiety
Depression
Sleep disturbance
Feeling faint
Varicose veins
Cancer (type)
Haemorrhoids
Numb feet on standing

Family Story

Please share any significant details of your birth family story if known; this may include physical or mental health, lifestyle, cause/age of death of your parents and any other details you feel are relevant.


Maternal

Paternal

Gut Health


Describe your relationship with food?

What were mealtimes like growing up?

What are mealtimes like now?

Do you have any food intolerances or allergies?

Do you follow a particular diet?

Click to customize text box label
Do you eat home cooked food?*

What is your typical daily intake of the following? 


Water

Caffeine

Alcohol
Do you experience any bloating, burbs or flatulence after eating?*
No
Yes

If so, what triggers this?

How often are your bowel movements?

Do you suffer from abdominal pain, constipation, diarrhea, incomplete bowel movements, thin stools, blood or mucus in your stools?

Mental & Emotional Health


How do you nurture yourself?

Where and how do you find joy?

Are you currently experiencing stress?

How do these affect your life and how do you manage them?

Do you have a faith or spiritual practice and if so, would you be willing to share this?

What exercise do you enjoy, and how often do you do it?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Have you experienced any traumatic events that you would be willing to share?

Have you considered seeking professional support?

Pelvic Health

Do you experience pelvic pain or congestion?*
No
Yes

If so, how does this affect you?
Do you experience pain in any of the following areas?
Uterus
Ovaries
Vagina
Vulva
Penis
Prostate
Testicles
Rectum
Pain during sex
Perineum
Do you experience any of the following urinary issues? If so, how does this affect you?
Incontinence – coughing, jumping
Overactive bladder
Night time urgency
Cystitis
Incomplete bladder emptying
Constant leakage
Interstitial Cystitis
Kidney Stones
Bladder cancer
Bladder prolapse
Bladder stones

Have you had any pelvic tests – PAP, PSA or STD?
Have you ever had abnormal results?*
No
Yes

If so when, and did you receive treatment?
Do you currently/have you use/used birth control? *
No
Yes
If so, please indicate which one:
Pill
Patch
Diaphragm
Injection
Condoms
IUD
Abstinence
Rhythm Method
Fertility Awareness Method

If hormonal, how long for:

Menstrual Health

Do you experience any of the following:
Painful periods
Absent period
Lower back pain before/during/after bleeding
Irregular cycles
Heaviness prior to period
Dark thick blood -start/end
Excessive bleeding
Clots
Dizziness
Bowel changes
Headache/migraine
Water retention
Endometriosis
Painful ovulation
Irregular ovulation
Lack of ovulation
Vaginal dryness
Bleeding/spotting during ovulation
Premature Ovarian Failure
Polyps - uterine/cervical
Fibroids - location/size/number
Cysts - location/size/number
Incontinence- bladder/bowel
Bloating

If Fibroids - please provide location/size/number

If Cysts - please provide location/size/number

How old were you when you started menstruating?

What was this like for you?

How many days is your menstrual cycle?

How many days is your bleed? Please include number of days spotting at beginning or end.

What menstrual products do you use?

Do you bleed through more than one tampon or pad per hour?

When was your last menstrual bleed?

How do you feel about your menstrual cycle?

Do you chart your cycle?

If so how – App, paper charts?
Do you know if your mother, sister or other close female relations have experienced any of the following issues?
Infertility
Fibroids
Endometriosis
Cancer
Menstrual issues
Menopause issues

Urogenital Health

Do you experience or have a history of any of the following:
Painful/burning on urination
Urinary retention
Frequent bladder infections
Blood/pus in urine
Pelvic pain/pressure
Night time urination
Changes in sex drive
Cystitis
Interstitial cystitis
Prostate disease or cancer
Urinary incontinence or dribbling
Difficult to start urination
Weak/interrupted urine flow
Pelvic injury or surgery
Sperm related fertility issues
Vulvodynia
Herpes
HPV
Bartholomew Cysts
Do you experience or have a history of pain/discomfort in:
Testicles
Penis
Rectum
Inner Thigh
Pelvic Floor/perineum
Erection pain/problems
Lower back pain especially after sex

Desire & Libido


Do you enjoy making love?

Do you climax?

Are you satisfied with your level of sexual desire?

Have you noticed any changes recently?

How do you feel about this?

Fertility & Pregnancy Health 


Are you hoping to conceive?

If so, how long have you been trying?
Have you or your partner had any pregnancies?*
No
Yes

If so, did you choose to continue with them and what were they like?

Have you experienced any loss?

Have you given or witnessed birth?

If so, what was the experience like?

How was your postpartum experience?

Have you had any fertility tests e.g. Sperm or egg reserve?

Are you under the care of a fertility specialist?

Please describe any treatment you may have received including - IUI, IVF, ICSI, Hormone treatment or Surgery.

Peri/Menopause Health


How do you feel about your menopausal journey?

What stories do you carry?

What positive menopausal role models do you have?

Are you keeping your menopausal journal?
Do you experience any of the following:
Hot flushes
Vaginal discharge
Increased libido
Decreased libido
Painful sex
Insomnia
Dry/itchy skin
Dry/itchy vagina
Vaginal Atrophy
Spotting
Flooding
Tiredness
Depression
Anxiety
Irregular menses
Poor memory
Mood swings
Irritability

When did you start to notice symptoms?

Are these changing, increasing or decreasing?
Have you noticed a connection between your symptoms and:
Diet
Work Load
Stress levels

Do you use, or have you ever used hormone replacement therapy or bio-identical hormones?

If so, which ones, and for how long?

Thank you for taking the time to share your information. 


Is there anything else you would like to tell me?
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Preferred pronoun

Gender currently identifying as

Gender assigned at birth

How did you hear about me and this work?

Abdominal Therapy is not a substitute for care by your medical doctor. Abdominal Therapy practitioners do not diagnose medical diseases, physical or mental conditions. Abdominal Therapy practitioners do not prescribe medical pharmaceuticals. 

COVID-19 Information

Have you had Covid-19?*
No
Yes

If so, when?
Are you vaccinated against Covid-19?*
No
Yes
Do you have any complaints in connection with the vaccination or the infection?*
No
Yes

If yes, can you describe these side effects?

I have stated all known conditions and will keep my practitioner updated on my health. By signing below, I confirm all the information I’ve provided is correct. I understand this information will remain confidential. 

What’s the reason for your visit?


Primary reason for this visit?

What would you like to achieve as a result of your visit?

When did you first notice this?

Do you feel something may have triggered this?

Describe any stressors occurring at this time?

What makes you feel better?

What makes you feel worse?

What changes or goals would you like to achieve over the next 3/6 months?

A Little bit of History


Are you taking any of the following – medication, supplementation, natural remedies? If so, please give details:

Do you use alcohol or recreational drugs? If so, how regularly and how do you feel about this?

Do you smoke? If so, how regularly and how do you feel about this?

Any allergies? If yes, what are you allergic to? What reaction do you have?

Have you experienced any of the following? If so, please share some details.


Surgery

Accidents

Injuries to sacrum/head/tailbone

Concerns

Do you, or have you ever suffered from any of the following:
Headache
Asthma
Cold hands/feet
Swollen ankles
Sinus conditions/colds
Seizures
Skin conditions
Lower back pain
Sciatica
Herniated/bulging discs
Painful/swollen joints
Neck/shoulder/jaw tension
High/low blood pressure
Sore heels when walking
Anxiety
Depression
Sleep disturbance
Feeling faint
Varicose veins
Cancer (type)
Haemorrhoids
Numb feet on standing

Family Story

Please share any significant details of your birth family story if known; this may include physical or mental health, lifestyle, cause/age of death of your parents and any other details you feel are relevant.


Maternal

Paternal

Gut Health


Describe your relationship with food?

What were mealtimes like growing up?

What are mealtimes like now?

Do you have any food intolerances or allergies?

Do you follow a particular diet?

Click to customize text box label
Do you eat home cooked food?*

What is your typical daily intake of the following? 


Water

Caffeine

Alcohol
Do you experience any bloating, burbs or flatulence after eating?*
No
Yes

If so, what triggers this?

How often are your bowel movements?

Do you suffer from abdominal pain, constipation, diarrhea, incomplete bowel movements, thin stools, blood or mucus in your stools?

Mental & Emotional Health


How do you nurture yourself?

Where and how do you find joy?

Are you currently experiencing stress?

How do these affect your life and how do you manage them?

Do you have a faith or spiritual practice and if so, would you be willing to share this?

What exercise do you enjoy, and how often do you do it?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Have you experienced any traumatic events that you would be willing to share?

Have you considered seeking professional support?

Pelvic Health

Do you experience pelvic pain or congestion?*
No
Yes

If so, how does this affect you?
Do you experience pain in any of the following areas?
Uterus
Ovaries
Vagina
Vulva
Penis
Prostate
Testicles
Rectum
Pain during sex
Perineum
Do you experience any of the following urinary issues? If so, how does this affect you?
Incontinence – coughing, jumping
Overactive bladder
Night time urgency
Cystitis
Incomplete bladder emptying
Constant leakage
Interstitial Cystitis
Kidney Stones
Bladder cancer
Bladder prolapse
Bladder stones

Have you had any pelvic tests – PAP, PSA or STD?
Have you ever had abnormal results?*
No
Yes

If so when, and did you receive treatment?
Do you currently/have you use/used birth control? *
No
Yes
If so, please indicate which one:
Pill
Patch
Diaphragm
Injection
Condoms
IUD
Abstinence
Rhythm Method
Fertility Awareness Method

If hormonal, how long for:

Menstrual Health

Do you experience any of the following:
Painful periods
Absent period
Lower back pain before/during/after bleeding
Irregular cycles
Heaviness prior to period
Dark thick blood -start/end
Excessive bleeding
Clots
Dizziness
Bowel changes
Headache/migraine
Water retention
Endometriosis
Painful ovulation
Irregular ovulation
Lack of ovulation
Vaginal dryness
Bleeding/spotting during ovulation
Premature Ovarian Failure
Polyps - uterine/cervical
Fibroids - location/size/number
Cysts - location/size/number
Incontinence- bladder/bowel
Bloating

If Fibroids - please provide location/size/number

If Cysts - please provide location/size/number

How old were you when you started menstruating?

What was this like for you?

How many days is your menstrual cycle?

How many days is your bleed? Please include number of days spotting at beginning or end.

What menstrual products do you use?

Do you bleed through more than one tampon or pad per hour?

When was your last menstrual bleed?

How do you feel about your menstrual cycle?

Do you chart your cycle?

If so how – App, paper charts?
Do you know if your mother, sister or other close female relations have experienced any of the following issues?
Infertility
Fibroids
Endometriosis
Cancer
Menstrual issues
Menopause issues

Urogenital Health

Do you experience or have a history of any of the following:
Painful/burning on urination
Urinary retention
Frequent bladder infections
Blood/pus in urine
Pelvic pain/pressure
Night time urination
Changes in sex drive
Cystitis
Interstitial cystitis
Prostate disease or cancer
Urinary incontinence or dribbling
Difficult to start urination
Weak/interrupted urine flow
Pelvic injury or surgery
Sperm related fertility issues
Vulvodynia
Herpes
HPV
Bartholomew Cysts
Do you experience or have a history of pain/discomfort in:
Testicles
Penis
Rectum
Inner Thigh
Pelvic Floor/perineum
Erection pain/problems
Lower back pain especially after sex

Desire & Libido


Do you enjoy making love?

Do you climax?

Are you satisfied with your level of sexual desire?

Have you noticed any changes recently?

How do you feel about this?

Fertility & Pregnancy Health 


Are you hoping to conceive?

If so, how long have you been trying?
Have you or your partner had any pregnancies?*
No
Yes

If so, did you choose to continue with them and what were they like?

Have you experienced any loss?

Have you given or witnessed birth?

If so, what was the experience like?

How was your postpartum experience?

Have you had any fertility tests e.g. Sperm or egg reserve?

Are you under the care of a fertility specialist?

Please describe any treatment you may have received including - IUI, IVF, ICSI, Hormone treatment or Surgery.

Peri/Menopause Health


How do you feel about your menopausal journey?

What stories do you carry?

What positive menopausal role models do you have?

Are you keeping your menopausal journal?
Do you experience any of the following:
Hot flushes
Vaginal discharge
Increased libido
Decreased libido
Painful sex
Insomnia
Dry/itchy skin
Dry/itchy vagina
Vaginal Atrophy
Spotting
Flooding
Tiredness
Depression
Anxiety
Irregular menses
Poor memory
Mood swings
Irritability

When did you start to notice symptoms?

Are these changing, increasing or decreasing?
Have you noticed a connection between your symptoms and:
Diet
Work Load
Stress levels

Do you use, or have you ever used hormone replacement therapy or bio-identical hormones?

If so, which ones, and for how long?

Thank you for taking the time to share your information. 


Is there anything else you would like to tell me?
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Preferred pronoun

Gender currently identifying as

Gender assigned at birth

How did you hear about me and this work?

Abdominal Therapy is not a substitute for care by your medical doctor. Abdominal Therapy practitioners do not diagnose medical diseases, physical or mental conditions. Abdominal Therapy practitioners do not prescribe medical pharmaceuticals. 

COVID-19 Information

Have you had Covid-19?*
No
Yes

If so, when?
Are you vaccinated against Covid-19?*
No
Yes
Do you have any complaints in connection with the vaccination or the infection?*
No
Yes

If yes, can you describe these side effects?

I have stated all known conditions and will keep my practitioner updated on my health. By signing below, I confirm all the information I’ve provided is correct. I understand this information will remain confidential. 

What’s the reason for your visit?


Primary reason for this visit?

What would you like to achieve as a result of your visit?

When did you first notice this?

Do you feel something may have triggered this?

Describe any stressors occurring at this time?

What makes you feel better?

What makes you feel worse?

What changes or goals would you like to achieve over the next 3/6 months?

A Little bit of History


Are you taking any of the following – medication, supplementation, natural remedies? If so, please give details:

Do you use alcohol or recreational drugs? If so, how regularly and how do you feel about this?

Do you smoke? If so, how regularly and how do you feel about this?

Any allergies? If yes, what are you allergic to? What reaction do you have?

Have you experienced any of the following? If so, please share some details.


Surgery

Accidents

Injuries to sacrum/head/tailbone

Concerns

Do you, or have you ever suffered from any of the following:
Headache
Asthma
Cold hands/feet
Swollen ankles
Sinus conditions/colds
Seizures
Skin conditions
Lower back pain
Sciatica
Herniated/bulging discs
Painful/swollen joints
Neck/shoulder/jaw tension
High/low blood pressure
Sore heels when walking
Anxiety
Depression
Sleep disturbance
Feeling faint
Varicose veins
Cancer (type)
Haemorrhoids
Numb feet on standing

Family Story

Please share any significant details of your birth family story if known; this may include physical or mental health, lifestyle, cause/age of death of your parents and any other details you feel are relevant.


Maternal

Paternal

Gut Health


Describe your relationship with food?

What were mealtimes like growing up?

What are mealtimes like now?

Do you have any food intolerances or allergies?

Do you follow a particular diet?

Click to customize text box label
Do you eat home cooked food?*

What is your typical daily intake of the following? 


Water

Caffeine

Alcohol
Do you experience any bloating, burbs or flatulence after eating?*
No
Yes

If so, what triggers this?

How often are your bowel movements?

Do you suffer from abdominal pain, constipation, diarrhea, incomplete bowel movements, thin stools, blood or mucus in your stools?

Mental & Emotional Health


How do you nurture yourself?

Where and how do you find joy?

Are you currently experiencing stress?

How do these affect your life and how do you manage them?

Do you have a faith or spiritual practice and if so, would you be willing to share this?

What exercise do you enjoy, and how often do you do it?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Have you experienced any traumatic events that you would be willing to share?

Have you considered seeking professional support?

Pelvic Health

Do you experience pelvic pain or congestion?*
No
Yes

If so, how does this affect you?
Do you experience pain in any of the following areas?
Uterus
Ovaries
Vagina
Vulva
Penis
Prostate
Testicles
Rectum
Pain during sex
Perineum
Do you experience any of the following urinary issues? If so, how does this affect you?
Incontinence – coughing, jumping
Overactive bladder
Night time urgency
Cystitis
Incomplete bladder emptying
Constant leakage
Interstitial Cystitis
Kidney Stones
Bladder cancer
Bladder prolapse
Bladder stones

Have you had any pelvic tests – PAP, PSA or STD?
Have you ever had abnormal results?*
No
Yes

If so when, and did you receive treatment?
Do you currently/have you use/used birth control? *
No
Yes
If so, please indicate which one:
Pill
Patch
Diaphragm
Injection
Condoms
IUD
Abstinence
Rhythm Method
Fertility Awareness Method

If hormonal, how long for:

Menstrual Health

Do you experience any of the following:
Painful periods
Absent period
Lower back pain before/during/after bleeding
Irregular cycles
Heaviness prior to period
Dark thick blood -start/end
Excessive bleeding
Clots
Dizziness
Bowel changes
Headache/migraine
Water retention
Endometriosis
Painful ovulation
Irregular ovulation
Lack of ovulation
Vaginal dryness
Bleeding/spotting during ovulation
Premature Ovarian Failure
Polyps - uterine/cervical
Fibroids - location/size/number
Cysts - location/size/number
Incontinence- bladder/bowel
Bloating

If Fibroids - please provide location/size/number

If Cysts - please provide location/size/number

How old were you when you started menstruating?

What was this like for you?

How many days is your menstrual cycle?

How many days is your bleed? Please include number of days spotting at beginning or end.

What menstrual products do you use?

Do you bleed through more than one tampon or pad per hour?

When was your last menstrual bleed?

How do you feel about your menstrual cycle?

Do you chart your cycle?

If so how – App, paper charts?
Do you know if your mother, sister or other close female relations have experienced any of the following issues?
Infertility
Fibroids
Endometriosis
Cancer
Menstrual issues
Menopause issues

Urogenital Health

Do you experience or have a history of any of the following:
Painful/burning on urination
Urinary retention
Frequent bladder infections
Blood/pus in urine
Pelvic pain/pressure
Night time urination
Changes in sex drive
Cystitis
Interstitial cystitis
Prostate disease or cancer
Urinary incontinence or dribbling
Difficult to start urination
Weak/interrupted urine flow
Pelvic injury or surgery
Sperm related fertility issues
Vulvodynia
Herpes
HPV
Bartholomew Cysts
Do you experience or have a history of pain/discomfort in:
Testicles
Penis
Rectum
Inner Thigh
Pelvic Floor/perineum
Erection pain/problems
Lower back pain especially after sex

Desire & Libido


Do you enjoy making love?

Do you climax?

Are you satisfied with your level of sexual desire?

Have you noticed any changes recently?

How do you feel about this?

Fertility & Pregnancy Health 


Are you hoping to conceive?

If so, how long have you been trying?
Have you or your partner had any pregnancies?*
No
Yes

If so, did you choose to continue with them and what were they like?

Have you experienced any loss?

Have you given or witnessed birth?

If so, what was the experience like?

How was your postpartum experience?

Have you had any fertility tests e.g. Sperm or egg reserve?

Are you under the care of a fertility specialist?

Please describe any treatment you may have received including - IUI, IVF, ICSI, Hormone treatment or Surgery.

Peri/Menopause Health


How do you feel about your menopausal journey?

What stories do you carry?

What positive menopausal role models do you have?

Are you keeping your menopausal journal?
Do you experience any of the following:
Hot flushes
Vaginal discharge
Increased libido
Decreased libido
Painful sex
Insomnia
Dry/itchy skin
Dry/itchy vagina
Vaginal Atrophy
Spotting
Flooding
Tiredness
Depression
Anxiety
Irregular menses
Poor memory
Mood swings
Irritability

When did you start to notice symptoms?

Are these changing, increasing or decreasing?
Have you noticed a connection between your symptoms and:
Diet
Work Load
Stress levels

Do you use, or have you ever used hormone replacement therapy or bio-identical hormones?

If so, which ones, and for how long?

Thank you for taking the time to share your information. 


Is there anything else you would like to tell me?
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Preferred pronoun

Gender currently identifying as

Gender assigned at birth

How did you hear about me and this work?

Abdominal Therapy is not a substitute for care by your medical doctor. Abdominal Therapy practitioners do not diagnose medical diseases, physical or mental conditions. Abdominal Therapy practitioners do not prescribe medical pharmaceuticals. 

COVID-19 Information

Have you had Covid-19?*
No
Yes

If so, when?
Are you vaccinated against Covid-19?*
No
Yes
Do you have any complaints in connection with the vaccination or the infection?*
No
Yes

If yes, can you describe these side effects?

I have stated all known conditions and will keep my practitioner updated on my health. By signing below, I confirm all the information I’ve provided is correct. I understand this information will remain confidential. 

What’s the reason for your visit?


Primary reason for this visit?

What would you like to achieve as a result of your visit?

When did you first notice this?

Do you feel something may have triggered this?

Describe any stressors occurring at this time?

What makes you feel better?

What makes you feel worse?

What changes or goals would you like to achieve over the next 3/6 months?

A Little bit of History


Are you taking any of the following – medication, supplementation, natural remedies? If so, please give details:

Do you use alcohol or recreational drugs? If so, how regularly and how do you feel about this?

Do you smoke? If so, how regularly and how do you feel about this?

Any allergies? If yes, what are you allergic to? What reaction do you have?

Have you experienced any of the following? If so, please share some details.


Surgery

Accidents

Injuries to sacrum/head/tailbone

Concerns

Do you, or have you ever suffered from any of the following:
Headache
Asthma
Cold hands/feet
Swollen ankles
Sinus conditions/colds
Seizures
Skin conditions
Lower back pain
Sciatica
Herniated/bulging discs
Painful/swollen joints
Neck/shoulder/jaw tension
High/low blood pressure
Sore heels when walking
Anxiety
Depression
Sleep disturbance
Feeling faint
Varicose veins
Cancer (type)
Haemorrhoids
Numb feet on standing

Family Story

Please share any significant details of your birth family story if known; this may include physical or mental health, lifestyle, cause/age of death of your parents and any other details you feel are relevant.


Maternal

Paternal

Gut Health


Describe your relationship with food?

What were mealtimes like growing up?

What are mealtimes like now?

Do you have any food intolerances or allergies?

Do you follow a particular diet?

Click to customize text box label
Do you eat home cooked food?*

What is your typical daily intake of the following? 


Water

Caffeine

Alcohol
Do you experience any bloating, burbs or flatulence after eating?*
No
Yes

If so, what triggers this?

How often are your bowel movements?

Do you suffer from abdominal pain, constipation, diarrhea, incomplete bowel movements, thin stools, blood or mucus in your stools?

Mental & Emotional Health


How do you nurture yourself?

Where and how do you find joy?

Are you currently experiencing stress?

How do these affect your life and how do you manage them?

Do you have a faith or spiritual practice and if so, would you be willing to share this?

What exercise do you enjoy, and how often do you do it?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Have you experienced any traumatic events that you would be willing to share?

Have you considered seeking professional support?

Pelvic Health

Do you experience pelvic pain or congestion?*
No
Yes

If so, how does this affect you?
Do you experience pain in any of the following areas?
Uterus
Ovaries
Vagina
Vulva
Penis
Prostate
Testicles
Rectum
Pain during sex
Perineum
Do you experience any of the following urinary issues? If so, how does this affect you?
Incontinence – coughing, jumping
Overactive bladder
Night time urgency
Cystitis
Incomplete bladder emptying
Constant leakage
Interstitial Cystitis
Kidney Stones
Bladder cancer
Bladder prolapse
Bladder stones

Have you had any pelvic tests – PAP, PSA or STD?
Have you ever had abnormal results?*
No
Yes

If so when, and did you receive treatment?
Do you currently/have you use/used birth control? *
No
Yes
If so, please indicate which one:
Pill
Patch
Diaphragm
Injection
Condoms
IUD
Abstinence
Rhythm Method
Fertility Awareness Method

If hormonal, how long for:

Menstrual Health

Do you experience any of the following:
Painful periods
Absent period
Lower back pain before/during/after bleeding
Irregular cycles
Heaviness prior to period
Dark thick blood -start/end
Excessive bleeding
Clots
Dizziness
Bowel changes
Headache/migraine
Water retention
Endometriosis
Painful ovulation
Irregular ovulation
Lack of ovulation
Vaginal dryness
Bleeding/spotting during ovulation
Premature Ovarian Failure
Polyps - uterine/cervical
Fibroids - location/size/number
Cysts - location/size/number
Incontinence- bladder/bowel
Bloating

If Fibroids - please provide location/size/number

If Cysts - please provide location/size/number

How old were you when you started menstruating?

What was this like for you?

How many days is your menstrual cycle?

How many days is your bleed? Please include number of days spotting at beginning or end.

What menstrual products do you use?

Do you bleed through more than one tampon or pad per hour?

When was your last menstrual bleed?

How do you feel about your menstrual cycle?

Do you chart your cycle?

If so how – App, paper charts?
Do you know if your mother, sister or other close female relations have experienced any of the following issues?
Infertility
Fibroids
Endometriosis
Cancer
Menstrual issues
Menopause issues

Urogenital Health

Do you experience or have a history of any of the following:
Painful/burning on urination
Urinary retention
Frequent bladder infections
Blood/pus in urine
Pelvic pain/pressure
Night time urination
Changes in sex drive
Cystitis
Interstitial cystitis
Prostate disease or cancer
Urinary incontinence or dribbling
Difficult to start urination
Weak/interrupted urine flow
Pelvic injury or surgery
Sperm related fertility issues
Vulvodynia
Herpes
HPV
Bartholomew Cysts
Do you experience or have a history of pain/discomfort in:
Testicles
Penis
Rectum
Inner Thigh
Pelvic Floor/perineum
Erection pain/problems
Lower back pain especially after sex

Desire & Libido


Do you enjoy making love?

Do you climax?

Are you satisfied with your level of sexual desire?

Have you noticed any changes recently?

How do you feel about this?

Fertility & Pregnancy Health 


Are you hoping to conceive?

If so, how long have you been trying?
Have you or your partner had any pregnancies?*
No
Yes

If so, did you choose to continue with them and what were they like?

Have you experienced any loss?

Have you given or witnessed birth?

If so, what was the experience like?

How was your postpartum experience?

Have you had any fertility tests e.g. Sperm or egg reserve?

Are you under the care of a fertility specialist?

Please describe any treatment you may have received including - IUI, IVF, ICSI, Hormone treatment or Surgery.

Peri/Menopause Health


How do you feel about your menopausal journey?

What stories do you carry?

What positive menopausal role models do you have?

Are you keeping your menopausal journal?
Do you experience any of the following:
Hot flushes
Vaginal discharge
Increased libido
Decreased libido
Painful sex
Insomnia
Dry/itchy skin
Dry/itchy vagina
Vaginal Atrophy
Spotting
Flooding
Tiredness
Depression
Anxiety
Irregular menses
Poor memory
Mood swings
Irritability

When did you start to notice symptoms?

Are these changing, increasing or decreasing?
Have you noticed a connection between your symptoms and:
Diet
Work Load
Stress levels

Do you use, or have you ever used hormone replacement therapy or bio-identical hormones?

If so, which ones, and for how long?

Thank you for taking the time to share your information. 


Is there anything else you would like to tell me?
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Preferred pronoun

Gender currently identifying as

Gender assigned at birth

How did you hear about me and this work?

Abdominal Therapy is not a substitute for care by your medical doctor. Abdominal Therapy practitioners do not diagnose medical diseases, physical or mental conditions. Abdominal Therapy practitioners do not prescribe medical pharmaceuticals. 

COVID-19 Information

Have you had Covid-19?*
No
Yes

If so, when?
Are you vaccinated against Covid-19?*
No
Yes
Do you have any complaints in connection with the vaccination or the infection?*
No
Yes

If yes, can you describe these side effects?

I have stated all known conditions and will keep my practitioner updated on my health. By signing below, I confirm all the information I’ve provided is correct. I understand this information will remain confidential. 

What’s the reason for your visit?


Primary reason for this visit?

What would you like to achieve as a result of your visit?

When did you first notice this?

Do you feel something may have triggered this?

Describe any stressors occurring at this time?

What makes you feel better?

What makes you feel worse?

What changes or goals would you like to achieve over the next 3/6 months?

A Little bit of History


Are you taking any of the following – medication, supplementation, natural remedies? If so, please give details:

Do you use alcohol or recreational drugs? If so, how regularly and how do you feel about this?

Do you smoke? If so, how regularly and how do you feel about this?

Any allergies? If yes, what are you allergic to? What reaction do you have?

Have you experienced any of the following? If so, please share some details.


Surgery

Accidents

Injuries to sacrum/head/tailbone

Concerns

Do you, or have you ever suffered from any of the following:
Headache
Asthma
Cold hands/feet
Swollen ankles
Sinus conditions/colds
Seizures
Skin conditions
Lower back pain
Sciatica
Herniated/bulging discs
Painful/swollen joints
Neck/shoulder/jaw tension
High/low blood pressure
Sore heels when walking
Anxiety
Depression
Sleep disturbance
Feeling faint
Varicose veins
Cancer (type)
Haemorrhoids
Numb feet on standing

Family Story

Please share any significant details of your birth family story if known; this may include physical or mental health, lifestyle, cause/age of death of your parents and any other details you feel are relevant.


Maternal

Paternal

Gut Health


Describe your relationship with food?

What were mealtimes like growing up?

What are mealtimes like now?

Do you have any food intolerances or allergies?

Do you follow a particular diet?

Click to customize text box label
Do you eat home cooked food?*

What is your typical daily intake of the following? 


Water

Caffeine

Alcohol
Do you experience any bloating, burbs or flatulence after eating?*
No
Yes

If so, what triggers this?

How often are your bowel movements?

Do you suffer from abdominal pain, constipation, diarrhea, incomplete bowel movements, thin stools, blood or mucus in your stools?

Mental & Emotional Health


How do you nurture yourself?

Where and how do you find joy?

Are you currently experiencing stress?

How do these affect your life and how do you manage them?

Do you have a faith or spiritual practice and if so, would you be willing to share this?

What exercise do you enjoy, and how often do you do it?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Have you experienced any traumatic events that you would be willing to share?

Have you considered seeking professional support?

Pelvic Health

Do you experience pelvic pain or congestion?*
No
Yes

If so, how does this affect you?
Do you experience pain in any of the following areas?
Uterus
Ovaries
Vagina
Vulva
Penis
Prostate
Testicles
Rectum
Pain during sex
Perineum
Do you experience any of the following urinary issues? If so, how does this affect you?
Incontinence – coughing, jumping
Overactive bladder
Night time urgency
Cystitis
Incomplete bladder emptying
Constant leakage
Interstitial Cystitis
Kidney Stones
Bladder cancer
Bladder prolapse
Bladder stones

Have you had any pelvic tests – PAP, PSA or STD?
Have you ever had abnormal results?*
No
Yes

If so when, and did you receive treatment?
Do you currently/have you use/used birth control? *
No
Yes
If so, please indicate which one:
Pill
Patch
Diaphragm
Injection
Condoms
IUD
Abstinence
Rhythm Method
Fertility Awareness Method

If hormonal, how long for:

Menstrual Health

Do you experience any of the following:
Painful periods
Absent period
Lower back pain before/during/after bleeding
Irregular cycles
Heaviness prior to period
Dark thick blood -start/end
Excessive bleeding
Clots
Dizziness
Bowel changes
Headache/migraine
Water retention
Endometriosis
Painful ovulation
Irregular ovulation
Lack of ovulation
Vaginal dryness
Bleeding/spotting during ovulation
Premature Ovarian Failure
Polyps - uterine/cervical
Fibroids - location/size/number
Cysts - location/size/number
Incontinence- bladder/bowel
Bloating

If Fibroids - please provide location/size/number

If Cysts - please provide location/size/number

How old were you when you started menstruating?

What was this like for you?

How many days is your menstrual cycle?

How many days is your bleed? Please include number of days spotting at beginning or end.

What menstrual products do you use?

Do you bleed through more than one tampon or pad per hour?

When was your last menstrual bleed?

How do you feel about your menstrual cycle?

Do you chart your cycle?

If so how – App, paper charts?
Do you know if your mother, sister or other close female relations have experienced any of the following issues?
Infertility
Fibroids
Endometriosis
Cancer
Menstrual issues
Menopause issues

Urogenital Health

Do you experience or have a history of any of the following:
Painful/burning on urination
Urinary retention
Frequent bladder infections
Blood/pus in urine
Pelvic pain/pressure
Night time urination
Changes in sex drive
Cystitis
Interstitial cystitis
Prostate disease or cancer
Urinary incontinence or dribbling
Difficult to start urination
Weak/interrupted urine flow
Pelvic injury or surgery
Sperm related fertility issues
Vulvodynia
Herpes
HPV
Bartholomew Cysts
Do you experience or have a history of pain/discomfort in:
Testicles
Penis
Rectum
Inner Thigh
Pelvic Floor/perineum
Erection pain/problems
Lower back pain especially after sex

Desire & Libido


Do you enjoy making love?

Do you climax?

Are you satisfied with your level of sexual desire?

Have you noticed any changes recently?

How do you feel about this?

Fertility & Pregnancy Health 


Are you hoping to conceive?

If so, how long have you been trying?
Have you or your partner had any pregnancies?*
No
Yes

If so, did you choose to continue with them and what were they like?

Have you experienced any loss?

Have you given or witnessed birth?

If so, what was the experience like?

How was your postpartum experience?

Have you had any fertility tests e.g. Sperm or egg reserve?

Are you under the care of a fertility specialist?

Please describe any treatment you may have received including - IUI, IVF, ICSI, Hormone treatment or Surgery.

Peri/Menopause Health


How do you feel about your menopausal journey?

What stories do you carry?

What positive menopausal role models do you have?

Are you keeping your menopausal journal?
Do you experience any of the following:
Hot flushes
Vaginal discharge
Increased libido
Decreased libido
Painful sex
Insomnia
Dry/itchy skin
Dry/itchy vagina
Vaginal Atrophy
Spotting
Flooding
Tiredness
Depression
Anxiety
Irregular menses
Poor memory
Mood swings
Irritability

When did you start to notice symptoms?

Are these changing, increasing or decreasing?
Have you noticed a connection between your symptoms and:
Diet
Work Load
Stress levels

Do you use, or have you ever used hormone replacement therapy or bio-identical hormones?

If so, which ones, and for how long?

Thank you for taking the time to share your information. 


Is there anything else you would like to tell me?
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Preferred pronoun

Gender currently identifying as

Gender assigned at birth

How did you hear about me and this work?

Abdominal Therapy is not a substitute for care by your medical doctor. Abdominal Therapy practitioners do not diagnose medical diseases, physical or mental conditions. Abdominal Therapy practitioners do not prescribe medical pharmaceuticals. 

COVID-19 Information

Have you had Covid-19?*
No
Yes

If so, when?
Are you vaccinated against Covid-19?*
No
Yes
Do you have any complaints in connection with the vaccination or the infection?*
No
Yes

If yes, can you describe these side effects?

I have stated all known conditions and will keep my practitioner updated on my health. By signing below, I confirm all the information I’ve provided is correct. I understand this information will remain confidential. 

What’s the reason for your visit?


Primary reason for this visit?

What would you like to achieve as a result of your visit?

When did you first notice this?

Do you feel something may have triggered this?

Describe any stressors occurring at this time?

What makes you feel better?

What makes you feel worse?

What changes or goals would you like to achieve over the next 3/6 months?

A Little bit of History


Are you taking any of the following – medication, supplementation, natural remedies? If so, please give details:

Do you use alcohol or recreational drugs? If so, how regularly and how do you feel about this?

Do you smoke? If so, how regularly and how do you feel about this?

Any allergies? If yes, what are you allergic to? What reaction do you have?

Have you experienced any of the following? If so, please share some details.


Surgery

Accidents

Injuries to sacrum/head/tailbone

Concerns

Do you, or have you ever suffered from any of the following:
Headache
Asthma
Cold hands/feet
Swollen ankles
Sinus conditions/colds
Seizures
Skin conditions
Lower back pain
Sciatica
Herniated/bulging discs
Painful/swollen joints
Neck/shoulder/jaw tension
High/low blood pressure
Sore heels when walking
Anxiety
Depression
Sleep disturbance
Feeling faint
Varicose veins
Cancer (type)
Haemorrhoids
Numb feet on standing

Family Story

Please share any significant details of your birth family story if known; this may include physical or mental health, lifestyle, cause/age of death of your parents and any other details you feel are relevant.


Maternal

Paternal

Gut Health


Describe your relationship with food?

What were mealtimes like growing up?

What are mealtimes like now?

Do you have any food intolerances or allergies?

Do you follow a particular diet?

Click to customize text box label
Do you eat home cooked food?*

What is your typical daily intake of the following? 


Water

Caffeine

Alcohol
Do you experience any bloating, burbs or flatulence after eating?*
No
Yes

If so, what triggers this?

How often are your bowel movements?

Do you suffer from abdominal pain, constipation, diarrhea, incomplete bowel movements, thin stools, blood or mucus in your stools?

Mental & Emotional Health


How do you nurture yourself?

Where and how do you find joy?

Are you currently experiencing stress?

How do these affect your life and how do you manage them?

Do you have a faith or spiritual practice and if so, would you be willing to share this?

What exercise do you enjoy, and how often do you do it?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Have you experienced any traumatic events that you would be willing to share?

Have you considered seeking professional support?

Pelvic Health

Do you experience pelvic pain or congestion?*
No
Yes

If so, how does this affect you?
Do you experience pain in any of the following areas?
Uterus
Ovaries
Vagina
Vulva
Penis
Prostate
Testicles
Rectum
Pain during sex
Perineum
Do you experience any of the following urinary issues? If so, how does this affect you?
Incontinence – coughing, jumping
Overactive bladder
Night time urgency
Cystitis
Incomplete bladder emptying
Constant leakage
Interstitial Cystitis
Kidney Stones
Bladder cancer
Bladder prolapse
Bladder stones

Have you had any pelvic tests – PAP, PSA or STD?
Have you ever had abnormal results?*
No
Yes

If so when, and did you receive treatment?
Do you currently/have you use/used birth control? *
No
Yes
If so, please indicate which one:
Pill
Patch
Diaphragm
Injection
Condoms
IUD
Abstinence
Rhythm Method
Fertility Awareness Method

If hormonal, how long for:

Menstrual Health

Do you experience any of the following:
Painful periods
Absent period
Lower back pain before/during/after bleeding
Irregular cycles
Heaviness prior to period
Dark thick blood -start/end
Excessive bleeding
Clots
Dizziness
Bowel changes
Headache/migraine
Water retention
Endometriosis
Painful ovulation
Irregular ovulation
Lack of ovulation
Vaginal dryness
Bleeding/spotting during ovulation
Premature Ovarian Failure
Polyps - uterine/cervical
Fibroids - location/size/number
Cysts - location/size/number
Incontinence- bladder/bowel
Bloating

If Fibroids - please provide location/size/number

If Cysts - please provide location/size/number

How old were you when you started menstruating?

What was this like for you?

How many days is your menstrual cycle?

How many days is your bleed? Please include number of days spotting at beginning or end.

What menstrual products do you use?

Do you bleed through more than one tampon or pad per hour?

When was your last menstrual bleed?

How do you feel about your menstrual cycle?

Do you chart your cycle?

If so how – App, paper charts?
Do you know if your mother, sister or other close female relations have experienced any of the following issues?
Infertility
Fibroids
Endometriosis
Cancer
Menstrual issues
Menopause issues

Urogenital Health

Do you experience or have a history of any of the following:
Painful/burning on urination
Urinary retention
Frequent bladder infections
Blood/pus in urine
Pelvic pain/pressure
Night time urination
Changes in sex drive
Cystitis
Interstitial cystitis
Prostate disease or cancer
Urinary incontinence or dribbling
Difficult to start urination
Weak/interrupted urine flow
Pelvic injury or surgery
Sperm related fertility issues
Vulvodynia
Herpes
HPV
Bartholomew Cysts
Do you experience or have a history of pain/discomfort in:
Testicles
Penis
Rectum
Inner Thigh
Pelvic Floor/perineum
Erection pain/problems
Lower back pain especially after sex

Desire & Libido


Do you enjoy making love?

Do you climax?

Are you satisfied with your level of sexual desire?

Have you noticed any changes recently?

How do you feel about this?

Fertility & Pregnancy Health 


Are you hoping to conceive?

If so, how long have you been trying?
Have you or your partner had any pregnancies?*
No
Yes

If so, did you choose to continue with them and what were they like?

Have you experienced any loss?

Have you given or witnessed birth?

If so, what was the experience like?

How was your postpartum experience?

Have you had any fertility tests e.g. Sperm or egg reserve?

Are you under the care of a fertility specialist?

Please describe any treatment you may have received including - IUI, IVF, ICSI, Hormone treatment or Surgery.

Peri/Menopause Health


How do you feel about your menopausal journey?

What stories do you carry?

What positive menopausal role models do you have?

Are you keeping your menopausal journal?
Do you experience any of the following:
Hot flushes
Vaginal discharge
Increased libido
Decreased libido
Painful sex
Insomnia
Dry/itchy skin
Dry/itchy vagina
Vaginal Atrophy
Spotting
Flooding
Tiredness
Depression
Anxiety
Irregular menses
Poor memory
Mood swings
Irritability

When did you start to notice symptoms?

Are these changing, increasing or decreasing?
Have you noticed a connection between your symptoms and:
Diet
Work Load
Stress levels

Do you use, or have you ever used hormone replacement therapy or bio-identical hormones?

If so, which ones, and for how long?

Thank you for taking the time to share your information. 


Is there anything else you would like to tell me?
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Preferred pronoun

Gender currently identifying as

Gender assigned at birth

How did you hear about me and this work?

Abdominal Therapy is not a substitute for care by your medical doctor. Abdominal Therapy practitioners do not diagnose medical diseases, physical or mental conditions. Abdominal Therapy practitioners do not prescribe medical pharmaceuticals. 

COVID-19 Information

Have you had Covid-19?*
No
Yes

If so, when?
Are you vaccinated against Covid-19?*
No
Yes
Do you have any complaints in connection with the vaccination or the infection?*
No
Yes

If yes, can you describe these side effects?

I have stated all known conditions and will keep my practitioner updated on my health. By signing below, I confirm all the information I’ve provided is correct. I understand this information will remain confidential. 

What’s the reason for your visit?


Primary reason for this visit?

What would you like to achieve as a result of your visit?

When did you first notice this?

Do you feel something may have triggered this?

Describe any stressors occurring at this time?

What makes you feel better?

What makes you feel worse?

What changes or goals would you like to achieve over the next 3/6 months?

A Little bit of History


Are you taking any of the following – medication, supplementation, natural remedies? If so, please give details:

Do you use alcohol or recreational drugs? If so, how regularly and how do you feel about this?

Do you smoke? If so, how regularly and how do you feel about this?

Any allergies? If yes, what are you allergic to? What reaction do you have?

Have you experienced any of the following? If so, please share some details.


Surgery

Accidents

Injuries to sacrum/head/tailbone

Concerns

Do you, or have you ever suffered from any of the following:
Headache
Asthma
Cold hands/feet
Swollen ankles
Sinus conditions/colds
Seizures
Skin conditions
Lower back pain
Sciatica
Herniated/bulging discs
Painful/swollen joints
Neck/shoulder/jaw tension
High/low blood pressure
Sore heels when walking
Anxiety
Depression
Sleep disturbance
Feeling faint
Varicose veins
Cancer (type)
Haemorrhoids
Numb feet on standing

Family Story

Please share any significant details of your birth family story if known; this may include physical or mental health, lifestyle, cause/age of death of your parents and any other details you feel are relevant.


Maternal

Paternal

Gut Health


Describe your relationship with food?

What were mealtimes like growing up?

What are mealtimes like now?

Do you have any food intolerances or allergies?

Do you follow a particular diet?

Click to customize text box label
Do you eat home cooked food?*

What is your typical daily intake of the following? 


Water

Caffeine

Alcohol
Do you experience any bloating, burbs or flatulence after eating?*
No
Yes

If so, what triggers this?

How often are your bowel movements?

Do you suffer from abdominal pain, constipation, diarrhea, incomplete bowel movements, thin stools, blood or mucus in your stools?

Mental & Emotional Health


How do you nurture yourself?

Where and how do you find joy?

Are you currently experiencing stress?

How do these affect your life and how do you manage them?

Do you have a faith or spiritual practice and if so, would you be willing to share this?

What exercise do you enjoy, and how often do you do it?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Have you experienced any traumatic events that you would be willing to share?

Have you considered seeking professional support?

Pelvic Health

Do you experience pelvic pain or congestion?*
No
Yes

If so, how does this affect you?
Do you experience pain in any of the following areas?
Uterus
Ovaries
Vagina
Vulva
Penis
Prostate
Testicles
Rectum
Pain during sex
Perineum
Do you experience any of the following urinary issues? If so, how does this affect you?
Incontinence – coughing, jumping
Overactive bladder
Night time urgency
Cystitis
Incomplete bladder emptying
Constant leakage
Interstitial Cystitis
Kidney Stones
Bladder cancer
Bladder prolapse
Bladder stones

Have you had any pelvic tests – PAP, PSA or STD?
Have you ever had abnormal results?*
No
Yes

If so when, and did you receive treatment?
Do you currently/have you use/used birth control? *
No
Yes
If so, please indicate which one:
Pill
Patch
Diaphragm
Injection
Condoms
IUD
Abstinence
Rhythm Method
Fertility Awareness Method

If hormonal, how long for:

Menstrual Health

Do you experience any of the following:
Painful periods
Absent period
Lower back pain before/during/after bleeding
Irregular cycles
Heaviness prior to period
Dark thick blood -start/end
Excessive bleeding
Clots
Dizziness
Bowel changes
Headache/migraine
Water retention
Endometriosis
Painful ovulation
Irregular ovulation
Lack of ovulation
Vaginal dryness
Bleeding/spotting during ovulation
Premature Ovarian Failure
Polyps - uterine/cervical
Fibroids - location/size/number
Cysts - location/size/number
Incontinence- bladder/bowel
Bloating

If Fibroids - please provide location/size/number

If Cysts - please provide location/size/number

How old were you when you started menstruating?

What was this like for you?

How many days is your menstrual cycle?

How many days is your bleed? Please include number of days spotting at beginning or end.

What menstrual products do you use?

Do you bleed through more than one tampon or pad per hour?

When was your last menstrual bleed?

How do you feel about your menstrual cycle?

Do you chart your cycle?

If so how – App, paper charts?
Do you know if your mother, sister or other close female relations have experienced any of the following issues?
Infertility
Fibroids
Endometriosis
Cancer
Menstrual issues
Menopause issues

Urogenital Health

Do you experience or have a history of any of the following:
Painful/burning on urination
Urinary retention
Frequent bladder infections
Blood/pus in urine
Pelvic pain/pressure
Night time urination
Changes in sex drive
Cystitis
Interstitial cystitis
Prostate disease or cancer
Urinary incontinence or dribbling
Difficult to start urination
Weak/interrupted urine flow
Pelvic injury or surgery
Sperm related fertility issues
Vulvodynia
Herpes
HPV
Bartholomew Cysts
Do you experience or have a history of pain/discomfort in:
Testicles
Penis
Rectum
Inner Thigh
Pelvic Floor/perineum
Erection pain/problems
Lower back pain especially after sex

Desire & Libido


Do you enjoy making love?

Do you climax?

Are you satisfied with your level of sexual desire?

Have you noticed any changes recently?

How do you feel about this?

Fertility & Pregnancy Health 


Are you hoping to conceive?

If so, how long have you been trying?
Have you or your partner had any pregnancies?*
No
Yes

If so, did you choose to continue with them and what were they like?

Have you experienced any loss?

Have you given or witnessed birth?

If so, what was the experience like?

How was your postpartum experience?

Have you had any fertility tests e.g. Sperm or egg reserve?

Are you under the care of a fertility specialist?

Please describe any treatment you may have received including - IUI, IVF, ICSI, Hormone treatment or Surgery.

Peri/Menopause Health


How do you feel about your menopausal journey?

What stories do you carry?

What positive menopausal role models do you have?

Are you keeping your menopausal journal?
Do you experience any of the following:
Hot flushes
Vaginal discharge
Increased libido
Decreased libido
Painful sex
Insomnia
Dry/itchy skin
Dry/itchy vagina
Vaginal Atrophy
Spotting
Flooding
Tiredness
Depression
Anxiety
Irregular menses
Poor memory
Mood swings
Irritability

When did you start to notice symptoms?

Are these changing, increasing or decreasing?
Have you noticed a connection between your symptoms and:
Diet
Work Load
Stress levels

Do you use, or have you ever used hormone replacement therapy or bio-identical hormones?

If so, which ones, and for how long?

Thank you for taking the time to share your information. 


Is there anything else you would like to tell me?
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Preferred pronoun

Gender currently identifying as

Gender assigned at birth

How did you hear about me and this work?

Abdominal Therapy is not a substitute for care by your medical doctor. Abdominal Therapy practitioners do not diagnose medical diseases, physical or mental conditions. Abdominal Therapy practitioners do not prescribe medical pharmaceuticals. 

COVID-19 Information

Have you had Covid-19?*
No
Yes

If so, when?
Are you vaccinated against Covid-19?*
No
Yes
Do you have any complaints in connection with the vaccination or the infection?*
No
Yes

If yes, can you describe these side effects?

I have stated all known conditions and will keep my practitioner updated on my health. By signing below, I confirm all the information I’ve provided is correct. I understand this information will remain confidential. 

What’s the reason for your visit?


Primary reason for this visit?

What would you like to achieve as a result of your visit?

When did you first notice this?

Do you feel something may have triggered this?

Describe any stressors occurring at this time?

What makes you feel better?

What makes you feel worse?

What changes or goals would you like to achieve over the next 3/6 months?

A Little bit of History


Are you taking any of the following – medication, supplementation, natural remedies? If so, please give details:

Do you use alcohol or recreational drugs? If so, how regularly and how do you feel about this?

Do you smoke? If so, how regularly and how do you feel about this?

Any allergies? If yes, what are you allergic to? What reaction do you have?

Have you experienced any of the following? If so, please share some details.


Surgery

Accidents

Injuries to sacrum/head/tailbone

Concerns

Do you, or have you ever suffered from any of the following:
Headache
Asthma
Cold hands/feet
Swollen ankles
Sinus conditions/colds
Seizures
Skin conditions
Lower back pain
Sciatica
Herniated/bulging discs
Painful/swollen joints
Neck/shoulder/jaw tension
High/low blood pressure
Sore heels when walking
Anxiety
Depression
Sleep disturbance
Feeling faint
Varicose veins
Cancer (type)
Haemorrhoids
Numb feet on standing

Family Story

Please share any significant details of your birth family story if known; this may include physical or mental health, lifestyle, cause/age of death of your parents and any other details you feel are relevant.


Maternal

Paternal

Gut Health


Describe your relationship with food?

What were mealtimes like growing up?

What are mealtimes like now?

Do you have any food intolerances or allergies?

Do you follow a particular diet?

Click to customize text box label
Do you eat home cooked food?*

What is your typical daily intake of the following? 


Water

Caffeine

Alcohol
Do you experience any bloating, burbs or flatulence after eating?*
No
Yes

If so, what triggers this?

How often are your bowel movements?

Do you suffer from abdominal pain, constipation, diarrhea, incomplete bowel movements, thin stools, blood or mucus in your stools?

Mental & Emotional Health


How do you nurture yourself?

Where and how do you find joy?

Are you currently experiencing stress?

How do these affect your life and how do you manage them?

Do you have a faith or spiritual practice and if so, would you be willing to share this?

What exercise do you enjoy, and how often do you do it?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Have you experienced any traumatic events that you would be willing to share?

Have you considered seeking professional support?

Pelvic Health

Do you experience pelvic pain or congestion?*
No
Yes

If so, how does this affect you?
Do you experience pain in any of the following areas?
Uterus
Ovaries
Vagina
Vulva
Penis
Prostate
Testicles
Rectum
Pain during sex
Perineum
Do you experience any of the following urinary issues? If so, how does this affect you?
Incontinence – coughing, jumping
Overactive bladder
Night time urgency
Cystitis
Incomplete bladder emptying
Constant leakage
Interstitial Cystitis
Kidney Stones
Bladder cancer
Bladder prolapse
Bladder stones

Have you had any pelvic tests – PAP, PSA or STD?
Have you ever had abnormal results?*
No
Yes

If so when, and did you receive treatment?
Do you currently/have you use/used birth control? *
No
Yes
If so, please indicate which one:
Pill
Patch
Diaphragm
Injection
Condoms
IUD
Abstinence
Rhythm Method
Fertility Awareness Method

If hormonal, how long for:

Menstrual Health

Do you experience any of the following:
Painful periods
Absent period
Lower back pain before/during/after bleeding
Irregular cycles
Heaviness prior to period
Dark thick blood -start/end
Excessive bleeding
Clots
Dizziness
Bowel changes
Headache/migraine
Water retention
Endometriosis
Painful ovulation
Irregular ovulation
Lack of ovulation
Vaginal dryness
Bleeding/spotting during ovulation
Premature Ovarian Failure
Polyps - uterine/cervical
Fibroids - location/size/number
Cysts - location/size/number
Incontinence- bladder/bowel
Bloating

If Fibroids - please provide location/size/number

If Cysts - please provide location/size/number

How old were you when you started menstruating?

What was this like for you?

How many days is your menstrual cycle?

How many days is your bleed? Please include number of days spotting at beginning or end.

What menstrual products do you use?

Do you bleed through more than one tampon or pad per hour?

When was your last menstrual bleed?

How do you feel about your menstrual cycle?

Do you chart your cycle?

If so how – App, paper charts?
Do you know if your mother, sister or other close female relations have experienced any of the following issues?
Infertility
Fibroids
Endometriosis
Cancer
Menstrual issues
Menopause issues

Urogenital Health

Do you experience or have a history of any of the following:
Painful/burning on urination
Urinary retention
Frequent bladder infections
Blood/pus in urine
Pelvic pain/pressure
Night time urination
Changes in sex drive
Cystitis
Interstitial cystitis
Prostate disease or cancer
Urinary incontinence or dribbling
Difficult to start urination
Weak/interrupted urine flow
Pelvic injury or surgery
Sperm related fertility issues
Vulvodynia
Herpes
HPV
Bartholomew Cysts
Do you experience or have a history of pain/discomfort in:
Testicles
Penis
Rectum
Inner Thigh
Pelvic Floor/perineum
Erection pain/problems
Lower back pain especially after sex

Desire & Libido


Do you enjoy making love?

Do you climax?

Are you satisfied with your level of sexual desire?

Have you noticed any changes recently?

How do you feel about this?

Fertility & Pregnancy Health 


Are you hoping to conceive?

If so, how long have you been trying?
Have you or your partner had any pregnancies?*
No
Yes

If so, did you choose to continue with them and what were they like?

Have you experienced any loss?

Have you given or witnessed birth?

If so, what was the experience like?

How was your postpartum experience?

Have you had any fertility tests e.g. Sperm or egg reserve?

Are you under the care of a fertility specialist?

Please describe any treatment you may have received including - IUI, IVF, ICSI, Hormone treatment or Surgery.

Peri/Menopause Health


How do you feel about your menopausal journey?

What stories do you carry?

What positive menopausal role models do you have?

Are you keeping your menopausal journal?
Do you experience any of the following:
Hot flushes
Vaginal discharge
Increased libido
Decreased libido
Painful sex
Insomnia
Dry/itchy skin
Dry/itchy vagina
Vaginal Atrophy
Spotting
Flooding
Tiredness
Depression
Anxiety
Irregular menses
Poor memory
Mood swings
Irritability

When did you start to notice symptoms?

Are these changing, increasing or decreasing?
Have you noticed a connection between your symptoms and:
Diet
Work Load
Stress levels

Do you use, or have you ever used hormone replacement therapy or bio-identical hormones?

If so, which ones, and for how long?

Thank you for taking the time to share your information. 


Is there anything else you would like to tell me?
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Preferred pronoun

Gender currently identifying as

Gender assigned at birth

How did you hear about me and this work?

Abdominal Therapy is not a substitute for care by your medical doctor. Abdominal Therapy practitioners do not diagnose medical diseases, physical or mental conditions. Abdominal Therapy practitioners do not prescribe medical pharmaceuticals. 

COVID-19 Information

Have you had Covid-19?*
No
Yes

If so, when?
Are you vaccinated against Covid-19?*
No
Yes
Do you have any complaints in connection with the vaccination or the infection?*
No
Yes

If yes, can you describe these side effects?

I have stated all known conditions and will keep my practitioner updated on my health. By signing below, I confirm all the information I’ve provided is correct. I understand this information will remain confidential. 

What’s the reason for your visit?


Primary reason for this visit?

What would you like to achieve as a result of your visit?

When did you first notice this?

Do you feel something may have triggered this?

Describe any stressors occurring at this time?

What makes you feel better?

What makes you feel worse?

What changes or goals would you like to achieve over the next 3/6 months?

A Little bit of History


Are you taking any of the following – medication, supplementation, natural remedies? If so, please give details:

Do you use alcohol or recreational drugs? If so, how regularly and how do you feel about this?

Do you smoke? If so, how regularly and how do you feel about this?

Any allergies? If yes, what are you allergic to? What reaction do you have?

Have you experienced any of the following? If so, please share some details.


Surgery

Accidents

Injuries to sacrum/head/tailbone

Concerns

Do you, or have you ever suffered from any of the following:
Headache
Asthma
Cold hands/feet
Swollen ankles
Sinus conditions/colds
Seizures
Skin conditions
Lower back pain
Sciatica
Herniated/bulging discs
Painful/swollen joints
Neck/shoulder/jaw tension
High/low blood pressure
Sore heels when walking
Anxiety
Depression
Sleep disturbance
Feeling faint
Varicose veins
Cancer (type)
Haemorrhoids
Numb feet on standing

Family Story

Please share any significant details of your birth family story if known; this may include physical or mental health, lifestyle, cause/age of death of your parents and any other details you feel are relevant.


Maternal

Paternal

Gut Health


Describe your relationship with food?

What were mealtimes like growing up?

What are mealtimes like now?

Do you have any food intolerances or allergies?

Do you follow a particular diet?

Click to customize text box label
Do you eat home cooked food?*

What is your typical daily intake of the following? 


Water

Caffeine

Alcohol
Do you experience any bloating, burbs or flatulence after eating?*
No
Yes

If so, what triggers this?

How often are your bowel movements?

Do you suffer from abdominal pain, constipation, diarrhea, incomplete bowel movements, thin stools, blood or mucus in your stools?

Mental & Emotional Health


How do you nurture yourself?

Where and how do you find joy?

Are you currently experiencing stress?

How do these affect your life and how do you manage them?

Do you have a faith or spiritual practice and if so, would you be willing to share this?

What exercise do you enjoy, and how often do you do it?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Have you experienced any traumatic events that you would be willing to share?

Have you considered seeking professional support?

Pelvic Health

Do you experience pelvic pain or congestion?*
No
Yes

If so, how does this affect you?
Do you experience pain in any of the following areas?
Uterus
Ovaries
Vagina
Vulva
Penis
Prostate
Testicles
Rectum
Pain during sex
Perineum
Do you experience any of the following urinary issues? If so, how does this affect you?
Incontinence – coughing, jumping
Overactive bladder
Night time urgency
Cystitis
Incomplete bladder emptying
Constant leakage
Interstitial Cystitis
Kidney Stones
Bladder cancer
Bladder prolapse
Bladder stones

Have you had any pelvic tests – PAP, PSA or STD?
Have you ever had abnormal results?*
No
Yes

If so when, and did you receive treatment?
Do you currently/have you use/used birth control? *
No
Yes
If so, please indicate which one:
Pill
Patch
Diaphragm
Injection
Condoms
IUD
Abstinence
Rhythm Method
Fertility Awareness Method

If hormonal, how long for:

Menstrual Health

Do you experience any of the following:
Painful periods
Absent period
Lower back pain before/during/after bleeding
Irregular cycles
Heaviness prior to period
Dark thick blood -start/end
Excessive bleeding
Clots
Dizziness
Bowel changes
Headache/migraine
Water retention
Endometriosis
Painful ovulation
Irregular ovulation
Lack of ovulation
Vaginal dryness
Bleeding/spotting during ovulation
Premature Ovarian Failure
Polyps - uterine/cervical
Fibroids - location/size/number
Cysts - location/size/number
Incontinence- bladder/bowel
Bloating

If Fibroids - please provide location/size/number

If Cysts - please provide location/size/number

How old were you when you started menstruating?

What was this like for you?

How many days is your menstrual cycle?

How many days is your bleed? Please include number of days spotting at beginning or end.

What menstrual products do you use?

Do you bleed through more than one tampon or pad per hour?

When was your last menstrual bleed?

How do you feel about your menstrual cycle?

Do you chart your cycle?

If so how – App, paper charts?
Do you know if your mother, sister or other close female relations have experienced any of the following issues?
Infertility
Fibroids
Endometriosis
Cancer
Menstrual issues
Menopause issues

Urogenital Health

Do you experience or have a history of any of the following:
Painful/burning on urination
Urinary retention
Frequent bladder infections
Blood/pus in urine
Pelvic pain/pressure
Night time urination
Changes in sex drive
Cystitis
Interstitial cystitis
Prostate disease or cancer
Urinary incontinence or dribbling
Difficult to start urination
Weak/interrupted urine flow
Pelvic injury or surgery
Sperm related fertility issues
Vulvodynia
Herpes
HPV
Bartholomew Cysts
Do you experience or have a history of pain/discomfort in:
Testicles
Penis
Rectum
Inner Thigh
Pelvic Floor/perineum
Erection pain/problems
Lower back pain especially after sex

Desire & Libido


Do you enjoy making love?

Do you climax?

Are you satisfied with your level of sexual desire?

Have you noticed any changes recently?

How do you feel about this?

Fertility & Pregnancy Health 


Are you hoping to conceive?

If so, how long have you been trying?
Have you or your partner had any pregnancies?*
No
Yes

If so, did you choose to continue with them and what were they like?

Have you experienced any loss?

Have you given or witnessed birth?

If so, what was the experience like?

How was your postpartum experience?

Have you had any fertility tests e.g. Sperm or egg reserve?

Are you under the care of a fertility specialist?

Please describe any treatment you may have received including - IUI, IVF, ICSI, Hormone treatment or Surgery.

Peri/Menopause Health


How do you feel about your menopausal journey?

What stories do you carry?

What positive menopausal role models do you have?

Are you keeping your menopausal journal?
Do you experience any of the following:
Hot flushes
Vaginal discharge
Increased libido
Decreased libido
Painful sex
Insomnia
Dry/itchy skin
Dry/itchy vagina
Vaginal Atrophy
Spotting
Flooding
Tiredness
Depression
Anxiety
Irregular menses
Poor memory
Mood swings
Irritability

When did you start to notice symptoms?

Are these changing, increasing or decreasing?
Have you noticed a connection between your symptoms and:
Diet
Work Load
Stress levels

Do you use, or have you ever used hormone replacement therapy or bio-identical hormones?

If so, which ones, and for how long?

Thank you for taking the time to share your information. 


Is there anything else you would like to tell me?
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Preferred pronoun

Gender currently identifying as

Gender assigned at birth

How did you hear about me and this work?

Abdominal Therapy is not a substitute for care by your medical doctor. Abdominal Therapy practitioners do not diagnose medical diseases, physical or mental conditions. Abdominal Therapy practitioners do not prescribe medical pharmaceuticals. 

COVID-19 Information

Have you had Covid-19?*
No
Yes

If so, when?
Are you vaccinated against Covid-19?*
No
Yes
Do you have any complaints in connection with the vaccination or the infection?*
No
Yes

If yes, can you describe these side effects?

I have stated all known conditions and will keep my practitioner updated on my health. By signing below, I confirm all the information I’ve provided is correct. I understand this information will remain confidential. 

What’s the reason for your visit?


Primary reason for this visit?

What would you like to achieve as a result of your visit?

When did you first notice this?

Do you feel something may have triggered this?

Describe any stressors occurring at this time?

What makes you feel better?

What makes you feel worse?

What changes or goals would you like to achieve over the next 3/6 months?

A Little bit of History


Are you taking any of the following – medication, supplementation, natural remedies? If so, please give details:

Do you use alcohol or recreational drugs? If so, how regularly and how do you feel about this?

Do you smoke? If so, how regularly and how do you feel about this?

Any allergies? If yes, what are you allergic to? What reaction do you have?

Have you experienced any of the following? If so, please share some details.


Surgery

Accidents

Injuries to sacrum/head/tailbone

Concerns

Do you, or have you ever suffered from any of the following:
Headache
Asthma
Cold hands/feet
Swollen ankles
Sinus conditions/colds
Seizures
Skin conditions
Lower back pain
Sciatica
Herniated/bulging discs
Painful/swollen joints
Neck/shoulder/jaw tension
High/low blood pressure
Sore heels when walking
Anxiety
Depression
Sleep disturbance
Feeling faint
Varicose veins
Cancer (type)
Haemorrhoids
Numb feet on standing

Family Story

Please share any significant details of your birth family story if known; this may include physical or mental health, lifestyle, cause/age of death of your parents and any other details you feel are relevant.


Maternal

Paternal

Gut Health


Describe your relationship with food?

What were mealtimes like growing up?

What are mealtimes like now?

Do you have any food intolerances or allergies?

Do you follow a particular diet?

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Do you eat home cooked food?*

What is your typical daily intake of the following? 


Water

Caffeine

Alcohol
Do you experience any bloating, burbs or flatulence after eating?*
No
Yes

If so, what triggers this?

How often are your bowel movements?

Do you suffer from abdominal pain, constipation, diarrhea, incomplete bowel movements, thin stools, blood or mucus in your stools?

Mental & Emotional Health


How do you nurture yourself?

Where and how do you find joy?

Are you currently experiencing stress?

How do these affect your life and how do you manage them?

Do you have a faith or spiritual practice and if so, would you be willing to share this?

What exercise do you enjoy, and how often do you do it?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?

Have you experienced any traumatic events that you would be willing to share?

Have you considered seeking professional support?

Pelvic Health

Do you experience pelvic pain or congestion?*
No
Yes

If so, how does this affect you?
Do you experience pain in any of the following areas?
Uterus
Ovaries
Vagina
Vulva
Penis
Prostate
Testicles
Rectum
Pain during sex
Perineum
Do you experience any of the following urinary issues? If so, how does this affect you?
Incontinence – coughing, jumping
Overactive bladder
Night time urgency
Cystitis
Incomplete bladder emptying
Constant leakage
Interstitial Cystitis
Kidney Stones
Bladder cancer
Bladder prolapse
Bladder stones

Have you had any pelvic tests – PAP, PSA or STD?
Have you ever had abnormal results?*
No
Yes

If so when, and did you receive treatment?
Do you currently/have you use/used birth control? *
No
Yes
If so, please indicate which one:
Pill
Patch
Diaphragm
Injection
Condoms
IUD
Abstinence
Rhythm Method
Fertility Awareness Method

If hormonal, how long for:

Menstrual Health

Do you experience any of the following:
Painful periods
Absent period
Lower back pain before/during/after bleeding
Irregular cycles
Heaviness prior to period
Dark thick blood -start/end
Excessive bleeding
Clots
Dizziness
Bowel changes
Headache/migraine
Water retention
Endometriosis
Painful ovulation
Irregular ovulation
Lack of ovulation
Vaginal dryness
Bleeding/spotting during ovulation
Premature Ovarian Failure
Polyps - uterine/cervical
Fibroids - location/size/number
Cysts - location/size/number
Incontinence- bladder/bowel
Bloating

If Fibroids - please provide location/size/number

If Cysts - please provide location/size/number

How old were you when you started menstruating?

What was this like for you?

How many days is your menstrual cycle?

How many days is your bleed? Please include number of days spotting at beginning or end.

What menstrual products do you use?

Do you bleed through more than one tampon or pad per hour?

When was your last menstrual bleed?

How do you feel about your menstrual cycle?

Do you chart your cycle?

If so how – App, paper charts?
Do you know if your mother, sister or other close female relations have experienced any of the following issues?
Infertility
Fibroids
Endometriosis
Cancer
Menstrual issues
Menopause issues

Urogenital Health

Do you experience or have a history of any of the following:
Painful/burning on urination
Urinary retention
Frequent bladder infections
Blood/pus in urine
Pelvic pain/pressure
Night time urination
Changes in sex drive
Cystitis
Interstitial cystitis
Prostate disease or cancer
Urinary incontinence or dribbling
Difficult to start urination
Weak/interrupted urine flow
Pelvic injury or surgery
Sperm related fertility issues
Vulvodynia
Herpes
HPV
Bartholomew Cysts
Do you experience or have a history of pain/discomfort in:
Testicles
Penis
Rectum
Inner Thigh
Pelvic Floor/perineum
Erection pain/problems
Lower back pain especially after sex

Desire & Libido


Do you enjoy making love?

Do you climax?

Are you satisfied with your level of sexual desire?

Have you noticed any changes recently?

How do you feel about this?

Fertility & Pregnancy Health 


Are you hoping to conceive?

If so, how long have you been trying?
Have you or your partner had any pregnancies?*
No
Yes

If so, did you choose to continue with them and what were they like?

Have you experienced any loss?

Have you given or witnessed birth?

If so, what was the experience like?

How was your postpartum experience?

Have you had any fertility tests e.g. Sperm or egg reserve?

Are you under the care of a fertility specialist?

Please describe any treatment you may have received including - IUI, IVF, ICSI, Hormone treatment or Surgery.

Peri/Menopause Health


How do you feel about your menopausal journey?

What stories do you carry?

What positive menopausal role models do you have?

Are you keeping your menopausal journal?
Do you experience any of the following:
Hot flushes
Vaginal discharge
Increased libido
Decreased libido
Painful sex
Insomnia
Dry/itchy skin
Dry/itchy vagina
Vaginal Atrophy
Spotting
Flooding
Tiredness
Depression
Anxiety
Irregular menses
Poor memory
Mood swings
Irritability

When did you start to notice symptoms?

Are these changing, increasing or decreasing?
Have you noticed a connection between your symptoms and:
Diet
Work Load
Stress levels

Do you use, or have you ever used hormone replacement therapy or bio-identical hormones?

If so, which ones, and for how long?

Thank you for taking the time to share your information. 


Is there anything else you would like to tell me?
Parent or Guardian's Signature*
Electronic Signature Consent*
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