Abdominal Therapy Intake Form

Please fill out this questionnaire 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.

Address

Country

State/Province

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?

Are you vaccinated against Covid-19?

Do you have any complaints connected with the vaccination or the infection?

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?

A Little Bit of History

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

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.

Do you eat home cooked food?

Mainly
Occasionally
Never

What is your typical daily intake of the following?

Do you experience any bloating, burbs or flatulence after eating?

Mental & Emotional Health

Do you experience pelvic pain or congestion?

Have you ever had abnormal results?

Do you currently/have you use/used birth control? If so, please indicate which one and if hormonal, how long for:

Pill
Patch
Diaphragm
Injection
Condoms
IUD
Abstinence
Rhythm Method

Do you chart your cycle?

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

Fertility & Pregnancy Health

Have you or your partner had any pregnancies?

Have you given or witnessed birth?

Peri/Menopause Health

Have you noticed a connection between your symptoms and:

Diet
Work Load
Stress levels

Thank you for taking the time to share your information.

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Abdominal Therapy Intake Form

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