Client intake form fertility

Tick any that apply

2 days prior to or during mensturation

If you think you are pregnant

IUD or Coil fitted

Active Infection

Increase in Temperature

Recent Abdominal Surgery

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

Menstural Health

Digestive Health

Emotional Health Spiritual

Are you experiencing any of the following?

Fertility Issues

Peri-Menopause

Menopause

Tick any that apply

Lower back ache

Dizziness change in Bowel Movements

Pain/Numbness in legs - Dark/Brown/Spotting at begining 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

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

Frustration/Irrtiabilty Excessive Anger

Lack of Self Worth/Highly Critical

Lack of Creativity/Lack of Enthusiasm

Tick all that apply

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

Methods of Delivery

Have you Exerienced?

Miscarriage

Termination

Ectopic

Stillbirth

What was your own birth and delivery experience ?

What areas would you like to see changes in?

Tick all that apply

The Fertile Womb Form