ࡱ> jlghi &bjbjss 2~ ~ 8$(dd(sssx(z(z(z(z(z(z($*-r(sQ"sss(("""sx("sx("":',' wmkOD' d((0(N'R.1l.'.'ss"sssss(("sss(ssss.sssssssss~ : Arvigo Techniques of Maya Abdominal Therapy (ATMAT) Female Confidential Intake Form Todays Date Name Date of Birth Address City State Zip Phone email Occupation Height Weight Emergency contact name & number Marital/Relationship status Referred by: Client Confidentiality Release Form I understand the treatment here is not a replacement for medical care. As such, the therapist/practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform any spinal manipulations (unless specified under his/her professional scope of practice) I understand that the treatment is not a substitute of medical treatments and/or diagnosis and it is recommended that I see a qualified professional for any physical or mental conditions that I may have. I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health. I understand that payment is due at the time of treatment unless arrangements have been made otherwise. I agree to give at least 72 hours notice of cancellation of appointment, otherwise will be expected to pay for session PLEASE INITIAL Client signature___________________________________________________Date____________________________ Reason For Visit Primary reason for visit: If applicable, what activities provide relief? What makes it worse? Is this condition getting worse? Interfere with work sleep recreation Have you had massage/bodywork before?______________ what type? Are you currently receiving any other body or energy therapies? If yes, what for? Are there any areas you do not like massaged (i.e. feet, head, etc.)? Are there any other areas youd like me to focus on today, time permitting? Is there anything specifically you hope to accomplish with this massage? Are you currently in pain or experiencing any discomfort? If so, please briefly explain and indicate those areas below. Mark X for pain and 0 for discomfort:  Describe any chronic pain/tension What makes it better? What makes it worse? Medical History Are you currently under the care of another health care provider(s)? Reason (s) Name(s) of Practitioner Address: Phone email Current Medications and /or Supplements/Remedies: Allergies: specify allergen and reaction: Surgical History (year and type) and/or Recent Procedures: Hospitalizations: Accidents or Traumas Falls/Injuries to Sacrum/head/tailbone (describe Other: Please review and check the following: Condition/ComplaintPastPresentCondition/ComplaintPast PresentHeadaches Type:  Pins and Needles in arms, legs, Hands or feet  AsthmaNeurological problemsCold Hands/feetSpinal ProblemsSwollen ankles Herniated/Bulging DiscsSinus ConditionsOsteoarthritisFrequent ColdsArthritisAllergies (specify above)AnxietyLoss of smell/tasteDepression/PanicSkin ConditionsSleep DisturbancePainful/Swollen JointsLoss of MemoryAuto-immune disorderWhiplashCancerBruise EasilyVaricose VeinsConstipation/DiarrheaBlood Clots/DVTContact LensesHeart ProblemsDentures/PartialsPacemakerHemorrhoidsHigh/Low BPArtificial/Missing limbsDiabetesMuscular TensionEpilepsy or SeizuresSciaticaFainting Spells Other (not mentioned above) Do you use Tobacco?______ Quantity_____/ppd Alcohol?____Quantitiy______ounces/ day Marijuana?_____Quantity______Other:______Have you been under treatment for substance use? Digestion and Elimination Typical Breakfast Typical Lunch Typical Dinner Snacks Water Intake (glasses/day) Caffeine What is the worst item in your diet Are you subject to binge eating? What foods? Do you experience bloating/gas/burps after eating? What foods trigger this? How often are your bowel movements? Do your stools: sink float Constipation? Blood in stool? Mucus in stool? Pain when stooling? Other concerns: Emotional & Spiritual What are hobbies/ activities that provide you with a sense of pleasure and accomplishment? Describe your exercise routine (type, frequency) What changes would you like to achieve in 6 months: One Year Female Reproductive Health History When did you begin your menses?___________What was this like for you? How many Pregnancies have you had? Number of Births_________Dates Terminations_____________When Miscarriages_____________When Complications What was your experience of: Pregnancy Labor Birthing Post Partum Birth Trauma (if known) Method of Contraception (circle) pills patch diaphragm injection condoms IUD abstinence rhythm method FAM other Length of time using method Last Pap smear Results (if known) Date of Last Menstrual period Length of Menses Are you Pregnant/Trying to Conceive Is there any possibility you are pregnant today/day of treatment? Episodes of Amenorrhea When For how long Are you under the treatment for fertility Describe current treatment to date (IUI, IVF, etc).: Gynecological Provider Address Phone Menstrual/Reproductive Health Please check as appropriate: Painful PeriodsIrregular Cycles (early or late)Dark, thick blood at beginning of cycleDark thick blood at the end of cycleHeadache or Migraine with periodDizziness with periodBloating/Water Retention with periodHeaviness in pelvis with periodPMS/Depression with or before periodExcessive Bleeding (> one pad/hour)Failure to OvulatePainful OvulationVaricose VeinsTired weak legsNumb legs and feet when standingSore heels when walkingLow back achePainful intercourseConstipationEndometriosisEndometritis/Uterine InfectionsUterine PolypsFibroidsVaginal Discharge/Vaginitis/Bladder Infections/IncontinenceChronic MiscarriageWeak newborn infantsPremature deliveriesIncompetent cervixSpotting with pregnancyPelvic InflammationSexually Transmitted diseaseDry VaginaDifficult menopauseCancer especially of reproductive areaCysts especially breast/ovarian Family History Relative Still Living? Cause of Death/age ofMajor Health Issues Mother Father Siblings Maternal Grandmother MaternalGrandfather Paternal Grandmothe Paternal GrandfatherMaternal Family History of (please circle) Infertility Fibroids Endometriosis Menopause PMS Cancer (type) Menstrual Problems Other Menopause (if applicable) Age symptoms began: Are they getting worse better same Are you on/ or ever been on hormone replacement therapy? If so, how long Name and dose_________________________________________________________________ Reason for stopping____________________________________________________________ Age of Mother at menopause:______Concerns/Experience__________________________________________ Check the following symptoms that apply to you: Hot flashes InsomniaFatigueMemory LossMood Swings Vaginal Discharge Dry VaginaDepressionAnxietyIrritabilitySpotting FloodingIrregular MensesPainful IntercourseIncreased Libido Decreased LibidoDisturbed Sleep Pattern Additional Comments:     Page  PAGE 1 of  NUMPAGES 6 %,45<UWdkpqr~ϿϯzfUzC1#h$sCh"5CJOJQJ^JaJ#h"B8h"5CJOJQJ^JaJ hW5>*CJOJQJ^JaJ&h$sCh}&5>*CJOJQJ^JaJ&h$sCh"5>*CJOJQJ^JaJh"B8CJOJQJ^JaJ$h"B8hVX6B*CJ ^JaJ phh(6B*CJ ^JaJ phhiQ6B*CJ ^JaJ ph$h"B8h"6B*CJ ^JaJ phhy6B*CJ ^JaJ phjh$sCUmHnHu5UVWqr& ' X Y gd"gd"1$$d!%d$&d!'d$N!O$P!Q$]^a$gd"B8~$ % & ' < F N X Y Z \ ɵɵɵɵɵɐ|j`Vh7 LOJQJ^Jh"OJQJ^J#h"B8h}&5CJOJQJ^JaJh$sCh"5>*h$sCh}&5>*&h$sCh}&5>*CJOJQJ^JaJ 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