HEALING SPACE MAYA ABDOMINAL MASSAGE ADDENDUM
Name:__________________________________________
Date:___________________
Present physical issue:_______________________________________________________________________________
When did your symptoms begin and how frequently do they occur?
_________________________________________________________________________________________________________
Do you (or have you) experience any emotional stress at, or around, the time?
_________________________________________________________________________________________________________
MEDICAL HISTORY
Have you been hospitalized for any reason? Please explain.
_________________________________________________________________________________________________________
Have you had any falls that have resulted in hitting your head or tailbone?
_________________________________________________________________________________________________________
Did you suffer any accidents or other physical trauma as a child?
_________________________________________________________________________________________________________
Do you have any allergies?_________ If so, to what?________________________________________________
Present weight:______________ One year ago:_____________ Five years ago:___________
WOMEN’S HEALTH
Please circle any of the following issues that you currently experience. Underline the issues
you have experienced in the past.
Currently pregnant
Fibroids
Hot flashes
Irregular PAP
Vaginal dryness
Endomeriosis
Difficult menopause
Ovarian cysts
Pelvic pain
Difficulty getting pregnant Vaginal infection
Breast pain
STD’s including HPV
Irregular menstrual cycles
Number of pregnancies:_______ Number of deliveries:_______ Vaginal:________ C-Section:________
Have you had any complications with delivery? __________________________________________________
Have you had any post partum issues? ____________________________________________________________
Have you had any miscarriages? _______ If so, when? _____________________________________________
Have you had any abortions? ________ If so, when? ________________________________________________
Method of contraception:____________________________________________________________________________
Do you have an IUD? ________________________________________________________________________________
Do you have pain with intercourse? _______________________________________________________________
Do you have difficulty achieving orgasm? _________________________________________________________
Do you have difficulty with incontinence (difficulty holding your urine)? ______________________
Date of your last period:___________________________
MENSTRUAL PATTERN (Check all that apply):
Painful menstruation
Blood clots
Irregular cycles
Dark, thick blood at onset
Dark, thick blood at conclusion
Heaviness in lower pelvis
Weakness/numbness in legs
Other:________________________________
How many days does your period last? ____________________________________________________________
What is the quality of your flow? (Light, medium, heavy)________________________________________
The date of your last pelvic exam: __________________________________________________________________
Have you ever been told that you have a tipped or tilted uterus? _______________________________
MENOPAUSE
Have you entered menopause? ______ If so, at what age? ________________________________________
Please circle all of the following symptoms you are experiencing:
Hot flashes
Memory loss
Depression
Insomnia
Mood swings
Fatigue
Do any of the women on your mother’s side of the family suffer from any of the following
issues?
Infertility____________ Menstrual problems______________ Difficult menopause__________________
Are you currently, or have you ever, taken: Birth control pills?_________________________________
Hormone replacement therapy? ___________________________________________________________________
GENERAL HEALTH
Do you have, or have you ever experienced, any of the following conditions?
Hepatitis
Frequent cold/flu
Acne
Skin rashes
Skin fungus
Sinus problems
Anorexia
Bulimia
other heart issues
Kidney problems
fainting spells
FAMILY HISTORY
Has anyone in your family suffered from a medical condition, an addiction, emotional
issues? ________________________________________________________________________________________________
LIFESTYLE CHOICES
Tobacco use: Yes No
How much/how often?______________________________________________
Alcohol use:
Yes No
How much/how often?______________________________________________
Caffeine use:
Yes No
How much/how often?______________________________________________
Other drug use: Yes No
How much /how often?_____________________________________________
How frequently do you exercise? Daily________ Weekly________ Rarely_________
Type of exercise: _____________________________________________________________________________________
DIET
What do you typically eat for breakfast? __________________________________________________________
What do you typically eat for lunch? _______________________________________________________________
What do you typically eat for dinner? ______________________________________________________________
How many times per week do you eat:
Beef
White rice
Soda pop
Pork
White bread
Coffee
Fish
Crackers
Black tea
Chicken
Chips
Milk
Canned foods
Ice cream
Other dairy
Desserts
How many glasses of water do you drink per day? _______________________________________________
What is your worst dietary habit? __________________________________________________________________
Do you have a habit of binge eating? ______ What foods? _________________________________________
Do you have a weakness for any foods? ___________________________________________________________
DIGESTION
Appetite:
Good Fair Poor Explain:_____________________________________________________
Digestion: Good Fair Poor Explain:_______________________________________________________
Do you experience bloating or gas after meals?___________ Sour burps/heartburn?_____________
Are you on a restricted diet?_________ Explain: _____________________________________________________
ELIMINATION
How often do you have a bowel movement? Daily, _______Times/week, Irregular
Do you have hard stools?_________ Do you have loose stools?___________
Urination: Normal
Scanty
More than 5 times daily
Burning
Strong odor
Dark color
Do you have a history of bladder/kidney infections? ________ If so, at what age?______________
STRESS LEVEL
How do you rate your level of stress? (0=no stress, 10=maximum stress)______________________
What are the major stressors in your life? _________________________________________________________
Who provides you stress in your life? ______________________________________________________________
How many hours of sleep do you get per night? __________________________________________________
Do you usually wake up feeling tired? _______________ Rested? _________________
Nerves: Good_________ Fair____________ Poor_____________
Anxiety: Often______________ Sometimes_____________ Seldom_______________
Depression: Often_______________ Sometimes______________ Seldom________________
Please explain your responses: _____________________________________________________________________
EMOTIONAL AND SPIRITUAL WELL BEING
If romantically involved, how would you rate your relationship? _______________________________
Did you experience any emotional/sexual traumas in your early or present life? (Examples:
Rape, great loss, suicide or death of a loved one, etc) Please explain briefly:
_________________________________________________________________________________________________________
What negative emotion(s) do you experience most often? ______________________________________
_________________________________________________________________________________________________________
When do you experience this/these emotions? __________________________________________________
_________________________________________________________________________________________________________
Where are you when you experience this emotion? _____________________________________________
What is your overall opinion of yourself? _________________________________________________________
Have you ever sought counseling? _____ Was it beneficial? ______________________________________
Do you pray to a higher power? _______ How often? ______________________________________________
Rate your level of the following: None
Some
Lots
Faith__________________________
Generosity___________________________
Hope__________________________
Humor________________________________
Charity________________________
Fun____________________________________
Are there any unrealized longings in your life?____ What are they?_____________________________
_________________________________________________________________________________________________________
WORK AND RECREATION
Do you enjoy your career? __________________________________________________________________________
Do you participate in activities outside of work?____ If so, what?________________________________
_________________________________________________________________________________________________________
Do you have any hobbies/interests? _______________________________________________________________
Do you have a satisfying life? _______________________________________________________________________