Today's Date
MM
DD
YYYY
Name
First Name
Last Name
Date of Birth
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
Email
Occupation
Referred by
Are you currently under the care of another healthcare provider?
Yes
No
If yes, why?
Name of Practitioner
First Name
Last Name
Address of practitioner
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Please list any medications, supplements or remedies you are currently taking
Do you have any allergies?
Yes
No
Please list the allergens and your reaction
General health conditions
Please check all that apply to you, including past and present conditions
Please describe any of the above conditions that currently affect you, include the type and location if relevant
Do you experience any of the following?
Do you use tobacco?
Yes
No
Do you use alcohol?
Yes
No
If yes, how many units per day/week/month?
When did your last period begin? If unsure, choose an approximate date
MM
DD
YYYY
How many days does your period last?
How long do your cycles tend to be?
What age were you when you had your first period?
Please list any symptoms you experience that signal to you your period is coming
Do you monitor your ovulation? Please give details of the signs of ovulation you experience if any
Reproductive conditions
Please check all that apply to you, including past conditions
Use this space to give details on any of the above conditions
Were you previously on any form of contraceptive? What was it, how long were you using it, and how long since you stopped using it?
Are you currently, or have you ever experienced fertility challenges?
Yes
No
If yes, describe your treatment (IUI, IVF etc)
If you feel comfortable sharing details here, and it's appropriate, please include how many eggs you had collected, how many eggs fertilised, how many embryos were transferred, and how many were frozen, did you reach your pregnancy test date, what was the outcome?
Have your ever been pregnant?
Yes
No
How many pregnancies have you had?
Please give the number of deliveries you have had
Please give the dates of each birth
Which methods of delivery have you experienced? Please check all that apply
Have you experienced any of the following?
Please use this space to add any further information you feel important to share
Please use this space to give details and results of any investigations you have had with regards t your gynaecological health and fertility
I understand that Fertility Reflexology treatment is not a replacement for medical care
*
I have read and agree
I understand that Fertility Reflexology treatment does not guarantee pregnancy
*
I have read and agree
I understand that Jade Adair does not diagnose medical illness, disease or any other physical or mental conditions
*
I have read and agree
As such Jade Adair does not prescribe medical treatment or pharmaceuticals
*
I have read and agree
I have stated all known conditions and take it upon myself to keep Jade updated on my health
*
I have read and agree
