Fertility Massage Consultation Form

Your details will be treated in confidence.
* (required)

Name *

Email *

Address *

Contact Number *

Date of Birth *

Marital Status

How did you find out about Fertility Massage? *

Reason for Visit/Primary Concern *

When did this first occur? *

Describe any stress that occurred at time of onset?

Is this condition interfering with:
WorkSleepRelationship

Menstrual and Fertility Conditions
Painful PeriodPainful OvulationIrregular PeriodsExcessive BleedingPCOS (polycystic Ovary Syndrome)FibroidsEndometriosisPremature Ovarian FailureFailure to OvulateLow AMHMiscarriage (once)Recurrent Miscarriage

Symptoms experienced prior to and during menstruation
Lower back acheHeadachesDizzinessChange in bowels i.e. Constipation/DiarrhoeaPainful/numbness in left legPainful/numbness in right legDark thick blood at beginning of menstruationDark thick blood at the end of menstruationBlood clotsCramps left sideCramps right sideCramps central lower abdomenHeaviness or pressure in lower pelvisDragging sensationIncreased Urination

Symptoms currently experiencing
Varicose veins left legVaricose veins right legBladder infectionsBladder weaknessFrequent urinationDifficulty experiencing orgasmsCold hands or feetAnxiety/DepressionTrouble with sleep onsetTrouble with sleep maintenanceTightness in chestDifficulty breathing into abdomen

Digestive Complaints
Constipation (<1 per day)DiarrhoeaIBSFormed bowel movements (sausage like)Loose bowel movementsHard bowel movementsNon-formed movements (pellets)Abdominal pain left sideAbdominal 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?

Menstrual & Pregnancy History

Age of menarche (period) & experience *

How many pregnancies have you had? *

Number of deliveries?

Dates of each birth

Method of delivery:
NaturalWater birthEpidural/PethidineForceps/VentouseC-sectionTerminationsMiscarriageEctopic

Enter further details here

If you have given birth, what was your experience of:

Pregnancy

Labour & Delivery

Post Partum

What are your feelings towards giving birth?

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 to 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

Please advise here of any allergies, medication, medical conditions, operations within last 6 months or recent injuries

Please read and tick to confirm:
Cancellations within 48 hours will incur a 50% charge.
Cancellations within 24 hours will incur a 100% charge.
I understand the treatment is not a replacement for medical care.
I understand that the therapist does not diagnose medical illness, disease or any other physical or mental conditions, prescribe medical treatment of pharmaceuticals, or perform any spinal manipulations.
I have stated all known conditions, and take it upon myself to keep the therapist updated on my health.

You will be required to sign this consultation form at your appointment.