Fertility Reflexology Consultation Form

*** PLEASE NOTE***

This consultation form is for Fertility Reflexology Consultations and treatments only. For a more in-depth fertility consultation a Fertility Support Consultation may be appropriate - it includes Arvigo Maya Therapy, Fertility Massage, Abdominal-Sacral Massage and Reflexology as well as ongoing support, reviews and coaching. For more information, click here

I appreciate you taking the time to complete the following consultation form as best you can. Each question will be discussed at your consultation to ensure that nothing is missed, but the more information you provide here, the better I can tailor your fertility reflexology consultation and subsequent treatment to your needs. 

Please complete and submit this form prior to your consultation.

Many thanks

Jade

 

 

Basic information
Today's Date
Today's Date
Name
Name
Date of Birth
Date of Birth
Address
Address
Medical History
Name of Practitioner
Name of Practitioner
Address of practitioner
Address of practitioner
General health conditions
Please check all that apply to you, including past and present conditions
Do you experience any of the following?
Reproductive Health History
When did your last period begin? If unsure, choose an approximate date
When did your last period begin? If unsure, choose an approximate date
Reproductive conditions
Please check all that apply to you, including past conditions
Fertility Information
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?
Pregnancy history
Which methods of delivery have you experienced? Please check all that apply
Have you experienced any of the following?
Please read and confirm