First name:

Last name:

Phone:

Email

Address:

Occupation:

Contradictions:

Please inform your therapist if any of the following are applicable, so that they can alter the treatment accordingly.

REASON FOR VISIT

What areas would you like us to focus on in your session?

Multi choice

Menstural health

Digestive Health

Emotional health spiritual

MENSTURAL AND FERTILITY HISTORY

Are you experiencing any of the following?

Multi choice

Fertility issues

Peri-menopause

Menopause

SYMPTOMS OR CONDITIONS YOU ARE CURRENTLY EXPERIENCING

SYMPTOMS EXPERIENCING PRIOR TO AND DURING MENSTURATION

Multi choice

Lower back ache

Dizziness change in bowel movements

Pain/numbness in legs, dark brown spotting at beginning of cycle

Dark brown spotting at end of cycle, blood clots larger than 10p in size

Cramps in lower abdomen, heaviness in lower abdomen

Dragging sensation, increased urination

PRE-MENSTURAL EMOTIONS

Do you find yourself experiencing any of the following in the week prior to your period, or any time if you are menopausal?

Multi choice

Frustration/irritabilty/excessive anger

Lack of self worth/highly critical

Lack of creativity, lack of enthusiam

Add any further comments:

DIGESTIVE HEALTH

Multi choice

Constipation (1 per day) Diarrhoea

IBS formed bowel movements (sausage)

Loose bowel movements, hard painful bowel movements

Non formed bowel movements (pellets), abdominal pain left side

Abdominal pain right side

PREVIOUS PREGNANCY AND BIRTH HISTORY

How many pregnancies have you had?

METHODS OF DELIVERY

HAVE YOU EXPEREINCED?

Multi choice

Miscarriage

Termination

Ectopic

Stillbirth

Number of Deliveries:

YOUR OWN BIRTH STORY

What was your own birth and delivery experience ?

Do you know HOW you were conceived? i.e.. Planned - Unwanted - Surprise etc..?

Did your mother talk positively about your birth experience?

EMOTIONAL AND SPIRITUAL

What areas would you like to see changes in?

Have you ever experienced or witnessed Sexual or Emotional Abuse as a child or adult?

Yes

No

MEDICAL HISTORY

Add any further comments:

Please read, confirm and sign before submitting your completed consultation form. Thank you.

Signature

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Client Declaration:

I confirm that the information I have provided is true and complete to the best of my knowledge. I understand that withholding relevant physical or mental health information may affect the suitability and safety of the services provided.

I confirm I have read and understood this declaration.

Electronic Signature (Type Your Full Name):

Date:

GDPR Compliance

Your personal data will be stored and be accessible by "The Fertile Womb". Your information will not be shared to any third party companies. We will only contact you with regards to Fertility Massage and associated matters and will never send spam

Medical Malpractise

Your details will be kept on record for 3 years once you have recieved your last treatment with Emily Teague.

Record Keeping

Your consultation forms are kept on file on a password protected computer and paper files are kept in a locked filing cabinet at my home address. Your files are not viewed or accessible by anyone other than Emily Teague, unless consent is given by yourself to share with other therapists.

Medical Information Required

The medical & emotional questions are required so that Emily Teague can provide a Holistic Treatment for you.

I have read and agreed to the GDPR appliance.

I have stated all known conditions and take it upon myself to keep Emily Teague updated on my health.

As such, Emily Teague does not prescribe medical treatment, pharmaceuticals.

I understand that Emily Teague does not diagnose medical illness, disease or any other physical or mental conditions.

FERTILE WOMB

Client Intake Form:

A compassionate space to understand you're unique journey

Please complete the form below:

REASON FOR VISIT

MENSTURAL AND FERTILITY HISTORY

SYMPTOMS OR CONDITIONS YOU ARE CURRENTLY EXPERIENCING

SYMPTOMS EXPERIENCING PRIOR TO AND DURING MENSTURATION

PRE-MENSTURAL EMOTIONS

DIGESTIVE HEALTH

PREVIOUS PREGNANCY AND BIRTH HISTORY

METHODS OF DELIVERY

HAVE YOU EXPEREINCED?

YOUR OWN BIRTH STORY

EMOTIONAL AND SPIRITUAL

MEDICAL HISTORY