PERSONAL INFORMATION

Email Address

Occupation

This gives me insight into your lifestyle, stress levels and activity levels, for example.

Emergency Contact

Please provide a name and a contact number of a person to contact in case of an emergency.

If yes, how many & how old are they?

It can provide a great insight into your lifestyle, stress levels, activity leves, etc.

SUBJECTIVE HISTORY

What brings you to me? What is your primary symptom, concern or problem? What challenge do you face at the moment.

Can you please describe your symptoms? What makes it worse? What makes it better? Please describe the sensations, thoughts and emotions your experience.

Can you tell me when or how this started? Often symptoms start after a stressful or traumatic life event, prolonged stress, birth, chronic vaginal infection, injury or prolonged use of medication, like antibiotics.

Are your symptoms triggered by any specific elements or conditions (e.g. specific foods, touch, day of cycle or activities) or do you flare up spontaneously? Please provide the details.

Does this challenge interfere with sleep, work, relationships? If yes, can you describe in what ways?

What support, assessments and/or treatments have you received for this concern with what result?

How would you rate your current well-being?

What is your intention for these sessions?

PAST MEDICAL HISTORY

Please provide details on treatments & prescribed medications.

Please provide more details.

Do you take any supplements? Where they prescribed by a health practitioner?

Number of pregnancies, type of deliveries and dates.

Please list any surgeries, especially pelvic or abdominal surgeries and dates.

Have you had any injuries or accidents at all, even in childhood? If yes, please provide details.

Any relevant medical history I might have missed?

YOUR STORY

Please describe your mothers pregnancy with you & your birth.

Please describe the relationship with your mother.

Please describe the relationship with your father.

Please describe the relationship between your parents.

If you have children, can you describe your birth experience/s? How did it affect your body and emotions? If you don't have children, please tell me what is your relationship with motherhood and what are your feelings towards giving birth?

Did you experience or witness any trauma, whether in childhood or later in life? Please provide the level of detail you feel comfortable with.

Did you ever experience or witness emotional or physical abuse or neglect (from primary care providers, others around you or partner)?

Did you ever experience sexual abuse? (You do not need to answer this question if you do not want to. If you do, please provide the level of detail you feel comfortable with).

Are you in a romantic relationship? (How does it make you feel? Do you feel seen, respected, cared for & loved?)

How is your relationship with family?

How are your friendships?

INTIMATE HEALTH

Do you or did you suffer with cystitis, thrush or other urinary tract infections?

Are you under treatment for infertility i.e. IVF?

Do you suffer from burning, pain (stabbing or dull) or discomfort in any parts of your body, especially in your abdomen, gluteal muscles, pelvic bowl, thighs or rectum?

Do your symptoms flare up when you are stressed or tired?

Do your symptoms flare up when you are constipated or when having a bowel movement?

Do you take any prescribed medications for the above symptoms (either topically or orally)? Please provide details.

Please list birth control used (past and present) and dates.

Anything else you would like to share?

YOUR MENSTRUAL CYCLE

Are you peri-menopausal or menopausal? If yes, answer the below questions from the time when you were bleeding.

How do you feel about menopause? What words do you use to describe it? How does it make you feel?

Please describe the experience of having your first period (how did you feel, did you know what it was, how did your parents react?)

Please describe your your relationship with your period and your blood (share what kind of words do you use to refer to you period, how do you speak about it and what do you feel when it comes).

Please provide the details on how long is your bleed, how regular, describe the bleeding patterns. Is it regular? painful? Heavy? Do you struggle with PMS?

Do you struggle with any symptoms after your bleed?

YOUR BODY

How would you describe the relationship you have with your body? How do you feel about its needs to eat, rest, sleep? Do you allow for your body to be heard?

Do you suffer from ay other symptoms anywhere in your body that are unrelated to the above?

Do you suffer from Benign Joint Hypermobility?

Please describe your sleep cycle and quality. Do you wake up rested? What time do you got to sleep? When do you wake up?

Could you please describe your diet? How do you think your wellbeing relates to what you eat? What is your relationship with food?

Do you exercise? Please provide details.

Do you have any allergies or sensitivities, not only dietary, but also chemical sensitivities or skin reactions? Please provide details.

YOUR MIND & EMOTIONS

What is your relationship with life like? How do you feel about life?

Do you suffer from depression, anxiety or any other mental health disorder? If yes, please provide details you feel comfortable with.

If you answered yes, how do you manage it?

What is your opinion of yourself?

SPIRITUAL & ENERGETIC

Do you consider yourself to be a spiritual being?

Do you have a regular spiritual practice?

SELF CARE

What does self-care mean to you?

What makes you feel better, generally?

Why makes you feel worse, generally?

Do you do the things that make you feel better everyday? If not, why?

Do you keep doing things that make you feel worse? If yes, why?

How does stress affect your body and your mind? Where do you feel stress in your body?

How do you relax?

Do you relax daily?

How do you take care of yourself?

Do you make sure you take time to care for yourself daily?

COMMITMENT TO YOUR WELLBEING

My approach is not going to work for you if you are not ready to take 100% responsibility for yourself, your story, your health & wellbeing and are looking for a quick fix. This work is for women ready to make necessary changes, face their emotions, leave the victim mentality and to commit fully to becoming well.

Do you believe that you can heal and and get better?

Are you committed to making necessary lifestyle changes to improve your wellbeing?

Are you ready to take full responsibility for yourself, nourishing your growth and expansion?

YOUR SESSION

What kind of tea do you like?

What kind of music makes you relaxed and safe?

What scent do you love?

ADDITIONAL INFORMATION

I there anything else you think or feel is relevant to me to know?

CONSENT & ACKNOWLEDGMENT