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
Preferred method of contact
Occupation
Referred by
Emergency contact
First Name
Last Name
Emergency Contact number
What is your primary reason
How long have you been experiencing this issue?
Do you know what may have triggered it?
Describe any stressors at the time of onset
What activities or practices provide relief?
What makes it worse?
Do you feel this condition is getting worse?
Does this condition interfere with
Have you ever received a professional massage before?
Yes
No
If yes, how often?
Weekly
Monthly
Annually
What type of pressure do you prefer?
Light
Medium
Firm
What are your goals for this session?
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
Please list any surgeries including recent procedures, include the type of treatment and the year
Have you experienced any hospitalisations, accidents or traumas?
Please describe any falls or injuries to your head, sacrum or tailbone
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
Describe your typical breakfast
Describe your typical lunch
Describe your typical dinner
How many litres of water do you drink per day
Less than 1 litre
1-2 litres
More than 2 litres
How many cups of tea or coffee do you drink daily?
None
1-3
4-6
More than 6
How do your eating habits change during times of stress?
What foods if any do your turn to for comfort?
Do you binge eat?
Yes
No
If yes, which foods?
Do you experience bloating/gas/burps after eating?
Yes
No
If yes, which foods trigger this?
Please describe any known or suspected food allergies, sensitivities or intolerances
How often are your bowel movements?
Do you experience any of the following?
Please use this space to share details of any other digestive concerns
Mother
Father
Siblings
List any hobbies or activities that give you a sense of accomplishment
Describe your feelings towards your work, if you work.
What is your opinion of yourself?
Describe the most positive emotion you experience, and where/when do you feel this?
Describe the most negative emotion you experience, and where/when do you feel this?
Describe your spiritual and/or religious practice, if you feel it's relevant for me to know
Describe your exercise routine (the type and frequency)
What changes would you like to achieve in 6 months?
What changes would you like to achieve in 1 year?
Do you use tobacco?
Yes
No
Do you use alcohol?
Yes
No
If yes, how many units per day/week/month?
Do you use marijuana?
Yes
No
If yes, how often?
Do you use any other substances? If yes, how much?
Have you received treatment for substance abuse? If yes, please explain
Please check the symptoms below that apply
Results of PSA (prostate specific antigen) Test if known
Date of PSA test
Result of of sperm count (if applicable and known)
Date of sperm test
Family History of Prostate Disease
If applicable, please give details of the type of prostate issue and your relationship to the person
Family history of cancer
If applicable, please give details about the type of cancer and your relationship to the person
Sexually transmitted disease
If applicable please give details about the type of STD/STI if known
Rate your interest in Sex
High
Moderate
Low
None
Have you had a traumatic experience? This may be sexual, physical, emotional, verbal or otherwise?
Yes
No
If yes, did you receive counselling for this? Did you find it helpful?
Are you and your partner currently trying to conceive?
Yes
No
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?
Has any members of your maternal family experienced any of the following
Do you have a family history of cancer? Please give details
Please give details of any medications your mother took whilst she was pregnant with you
Please give details of your birth trauma, if known
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 Arvigo Therapy treatment is not a replacement for medical care
*
I have read and agree
I understand that Arvigo Therapy 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
