First name

Last name

Phone

Address

Email

Occupation

Contraindications

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?

Menstural Health

Digestive Health

Emotional Health Spiritual

Menstrual and Fertility History:

Are you experiencing any of the following?

Fertility Issues

Peri - Menopause

Menopause

Symptoms or Conditions you are currently experiencing

Symptoms experienced prior to and during Menstruation

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

Frustration/IIrritablity/Excessive Anger

Lack of self worth/ highly critical

Lack of Creativity/Lack of Enthusiam

Add any further comments

Digestive Health

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?

Have you experienced?

Miscarriage

Termination

Ectopic

Stillbirth

Number of Deliveries

Your OWN Birth Story

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

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.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

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 compliance

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

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