Honouring the Womb Consultation Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Date of Birth
Number of children and dates of birth
Reason for treatment -What is your primary concern?
How long has this been an issue?
Describe any stress occurring at the time of onset
Is this condition interfering with- Sleep? Work? Relationships?
Menstrual and Fertility Conditions
painful periods
painful ovulation
irregular periods
excessive bleeding (>1 pad/tampon per hour)
PCOS (Polycystic Ovarian Syndrome)
PCO (Polycycstic Ovaries)
Fibroids
endometriosis
POF (Premature Ovarian Failure)
Failure to ovulate
Low AMH
Miscarriage (once)
Recurrent Miscarriage
N/A
Symptoms experienced prior to and during menstruation
lower back ache
headaches
dizziness
Change in bowels i.e. Constipation/Diarrhoea
Painful/numbness in left leg
Painful/numbness in right leg
Dark thick blood at beginning of menstruation
Dark thick blood at end of menstruation
blood clots
cramps left side
cramps right side
cramps central
cramps lower abdomen
heaviness or pressure in lower pelvis
dragging sensation
increased urination
N/A
Do you track your cycle? If so, what cycle day are you on?
Symptoms currently experiencing
Varicose veins left leg
Varicose veins right leg
Bladder infections
Bladder weakness
Frequent urination
Difficulty experiencing orgasms
Cold hands or feet
Anxiety/Depression
Trouble with sleep onset
Trouble with sleep maintenance
Tightness in chest
Difficulty breathing into abdomen
Digestive Complaints
Constipation
Diarrhoea
IBS
Formed bowel movements (sausage like)
Loose bowel movements
Hard bowel movements
Unformed bowel movements (pellets)
Abdominal pain left side
Abdominal pain right side
Medical History
Are you under treatment for infertility i.e. IVF
Have you had any surgery on your abdomen/lower back?
Accidents or traumas?
Falls or injuries to Sacrum, tailbone or head?
Recent procedures (please state)
high/low blood pressure
Other relevant medical conditions
Do you exercise regularly, if so what form of exercise does it take?
give additional details to medical history
Menstrual & Pregnancy History: Age of menarche (period) & experience
How many pregnancies have you had?
Number of deliveries?
Dates of each birth including method of delivery- natural, water birth, epidural/pethidine, forceps/ventouse, c-section. Also include any information on terminations, miscarriage, ectopic pregnancies. Scan the questions below before answering.
If you have given birth what was your experience of: Pregnancy
If you have given birth what was your experience of: Labour & Delivery
If you have given birth what was your experience of: Post Partum
What Stage of life do you see yourself at? (Still mothering/perimenopause/menopause)
If you have had a hysterectomy/surgery around your reproductive system, how do you feel about this?
Emotional & Spiritual - What is your opinion of yourself?
If possible, please describe the most negative emotion you experience.
When do you most often feel this emotion?
Have you witnessed or experienced: Emotional abuse/Physical abuse/ In childhood? As an adult?
What changes would you like achieve in the next 6 months?
What changes would you like achieve in the next 12 months?
Other Comments: Please use this space to give any further relevant information that you feel would be beneficial for me to know prior to your treatment
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