Intake Forms

Thank you for booking an appointment. Please choose one of the buttons below to go to the correct intake form. Please complete your form and return it to me at least 24 hours before we meet.

I look forward to working with you.

Digestive Health

Female Reproductive Health

Male Reproductive Health

Name:

Address:

Telephone:

Email:

Date of Birth:

Occupation:

GP Name:

GP Address:

GP Telephone:

How did you hear about me:

Client Confidentiality & Consent to Treatment

Please Click To Read My Terms And Conditions. Then Click Agree.

I Agree To The Terms:

Tick Here:

About You

Please briefly describe your reason for seeking treatment:

Is there anything you would like to achieve/change in the next 12 months?

Please list any diagnoses you have received from your doctor/specialist concerning your current or past physical or mental health

List any current medication including prescription/over-the-counter drugs (e.g. antibiotics, antihistamines, steroids, inhalers). Also include vitamins, nutritional supplements etc.

Do you have any allergies or food intolerances?

Please list any surgery, accidents or traumas - in particular any falls or injuries to the sacrum/tailbone/head

On a scale of 1 to 10 how do you feel? (where 1 is poor and 10 is excellent)

Emotionally:

Physically:

Energetically:

Where (if anywhere) do you notice that you hold tension in your body?

Do you exercise? if so how often and what type of exercise?

Do you drink alcohol? If so, approximately how many units per week?

Do you smoke? if so how many per day?

Digestive Health:

Please briefly describe your typical diet and any ‘weaknesses' or cravings

How much water do you drink?

How much caffeine do you drink?

Do you suffer with any of the following?

Gas/Burps:

Bloating:

Diarrhoea:

Blood in stools:

Mucous in stools:

Constipation:

Female Reproductive Health

What age did you start your periods? And what was it like for you?

How many days do you bleed for? And how long is your overall cycle (i.e 28 days)?

Date your last period started?

Are you pregnant or trying to conceive?

What contraception do you use? Are you or have you ever been on the birth control pill?

Date of last smear & results:

Are you having Fertility treatment? If so, please describe and give details of your specialist:

Pregnancy History

Please describe number (and dates) of pregnancies and births and any relevant conditions or complications. How was this experience for you?

Briefly describe the story of your own birth if known

Does your mother maternal aunt/s maternal grandmother have a history of any of the following?

Menstrual problems:

Fibroids:

Cancer (if yes what type)?

Cancer Type:

Endometriosis:

Cysts/PCOS:

Other:

More On Female Reproductive Health

Do you know the age of your mother/grandmother at menopause?

Rate your interest in sex:

Do you have difficulty experiencing orgasms?

Do you have a history of sexual trauma? If so did you receive counselling for this?

Have you ever suffered with any of the following?

PMT:

Heaviness in pelvis before/during period:

Painful periods:

Dark thick or brown blood? Beginning/end of period:

Clots in period:

Excessive bleeding:

Frequent need to urinate:

More during period:

Headaches or migraines with cycle:

Dizziness/Nausea:

Irregular cycles:

Early/Late:

Painful ovulation:

Failure to ovulate:

Endometriosis.:

Location:

Uterine or cervical polyps:

Fibroids.:

Location/type:

Uterine infection:

Vaginal infections:

Bladder infection:

Painful intercourse:

Position:

Lower back pain:

Spinal problems:

Painful joints:

Sciatica:

Pins and needles in arms, legs, hands, feet:

Swollen ankles:

Cold hands or feet:

Loss of smell or taste:

Sinus conditions / Frequent colds:

Varicose veins/ Haemorrhoids:

Blood Pressure:

High or Low:

Anxiety:

Depression:

Insomnia/Sleep disturbance:

Hot flashes:

Mood swings:

Fatigue:

Increased libido:

Decreased libido:

Cancer:

Type:

Male Reproductive Health
Please check the symptoms below that apply

Urinary incontinence or dribbling:

Weak or interrupted urine flow:

Pain or burning with urination:

Nocturnal urination:

How many times:

Pain in lower back, esp after intercourse:

Pain or discomfort in:

Penis:

Testicles:

Rectum:

Frequent bladder or kidney infections:

When:

Blood or pus in urine:

Pelvic pressure:

Insatiable sex drive:

Pain or discomfort between scrotum and testicles :

Pain or discomfort in inner thighs:

Left:

Right:

Both:

Penile function

Difficulty in obtaining an erection:

Difficulty maintaining an erection:

Painful ejaculation:

Have you recently had a PSA (prostate specific antigen) test? Date and results?

Have you recently had a sperm count? Date and results

Is there any family history of prostate disease?

Is there any family history of cancer?

Have you ever had a sexually transmitted disease?

Rate your interest in sex

Do you have a history of sexual trauma? If so did you receive counselling for this?

Family Health History

Please give brief details of your family’s health history. Describing any major health issues or cause and age of death.

Mother’s Side

Grandfather:

Grandmother:

Mother:

Aunts/Uncles/Cousins:

Father’s Side:

Grandfather.:

Grandmother.:

Mother.:

Father.:

Aunts/Uncles/Cousins.:

Siblings.:

Any other family history that you know of

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