Womb & Pelvic Healing Intake & Release Form

CONTACT INFORMATION
Today's Date
Today's Date
Name *
Name
What name would you like me to call you?
Legal Name
Legal Name
What is your legal name, if different?
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
It's okay to contact you by *
Their name, your relationship to them and their phone number
PRACTITIONER INFORMATION
It's helpful to know if you are under the care of other practitioners. Sometimes it is possible to coordinate care, with your consent.
Are you under the care of another healthcare provider? *
Including naturopaths, acupuncturists, therapists, etc.
Please include the name, type of practitioner, address and contact information for them.
INTENTION-SETTING
What do you attribute this to?
If you receive Maya abdominal massage, you understand that we will be working right off the pubic bone on the front and the tailbone on the back. Is this okay with you? *
If you receive Holistic Pelvic Care, you understand that we will be working intravaginally with the connective tissues of your pelvic bowl. Is this okay with you? *
ALL ABOUT YOUR CYCLE
When did your last menses begin?
When did your last menses begin?
Average day of cycle (for example 28 days). If irregular, note how they are irregular here.
If so, what size and color?
If so, how do you experience it?
REPRODUCTIVE HISTORY
Do you currently have an IUD? *
Y/N Feel free to discuss any changes you may notice.
Y/N If so, what kind?
Reproductive Symptoms
PREGNANCY HISTORY
Include any pertinent details, eg vaginal birth, cesarean birth, etc.
This may include miscarriages, still births and even abortions to some.
HISTORY OF TRAUMAS
The following questions are of a sensitive nature. Only answer what you feel comfortable answering. The pelvis and abdomen are especially vulnerable places that tend to store held emotions and also happen to be the least contacted parts of our bodies. Because of this, it is helpful for us to know your history with trauma so that we can create the safest and most respectful environment possible for you.
GENERAL MEDICAL HISTORY
Include years when possible, and if you are undergoing treatment currently for this condition. Include allergies to oils, fruits or nuts, if relevant.
LIFESTYLE, EMOTIONAL & SPIRITUAL
If personally meaningful for you, describe how you culturally identify. How do you relate to your culture(s)?
CONSENT & RELEASE
I am aware of the contraindications of various modalities that may be practiced listed below. By signing this form, I agree that they do not currently apply to me. You should NOT these modalities if the following contraindications apply to you Arvigo® Techniques of Maya Abdominal Therapy Deep abdominal massage will not be performed if ❂ You have an IUD ❂ You’re currently menstruating ❂ You’re pregnant ❂ You’re currently miscarrying ❂ You’re trying to conceive and have already ovulated Holistic Pelvic Care™ Internal pelvic floor work will not be performed if ❂ You’re pregnant ❂ You’re currently miscarrying ❂ You’re trying to conceive and have already ovulated ❂ You have a history of severe trauma that has not received counseling Herbal Pelvic Steams (Vaginal Steams) Pelvic steam baths will not be performed if ❂ You’re pregnant ❂ You're currently menstruating or actively bleeding ❂ You’re currently miscarrying ❂ You’re trying to conceive and have already ovulated ❂ You have a history of severe trauma that has not received counseling ❂ You’re prone to spontaneous, heavy bleeding Use caution if: ❂ You have an IUD, as this carries a small but possible risk of expelling the IUD
Please take a moment to carefully read the following information and sign by typing your initials below. If you have a specific medical condition or specific symptoms, any of these modalities may be contraindicated. A referral from your primary care provider may be required prior to service being provided. I understand that if I experience any pain or discomfort during any session, I will immediately inform the practitioner. Additionally, if I am receiving a vaginal steam bath, I will let the practitioner know if the heat is too hot so that the temperature may be adjusted to my level of comfort. I further understand that these modalities should not be construed as a substitute for medical examination, therapy, diagnosis, or treatment and that I should see a physician, therapist or other qualified medical or counseling specialist for any physical or mental ailment of which I am aware. I understand that the practitioner facilitating the healing is not qualified to diagnose, prescribe, and/or treat any physical or mental illness, and that nothing said in the course of any session given should be construed as such. Because each of the above named modalities should not be performed under certain medical conditions, I affirm that I have stated all of my known medical conditions, and answered all questions accurately, completely, and honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I forget to do so. I am aware and I understand there is a possibility that my IUD can come out due to a Maya Abdominal Therapy session or a Vaginal Steam Bath. This has been explained to me and I am going ahead with the Vaginal Steam Bath at my own risk. I understand that I am proceeding to receive any of these healing modalities at my own risk and hereby release Jeevan Singh from any liability.