Womb & Fertility Massage ~ Client Intake Form

Please note the following is contraindicated to receiving the full Womb & Fertility Massage Treatment. If any of the below apply to you, please tick so the treatment can be adjusted accordingly.

Pedunculated fibroids

Actively trying to conceive and post ovulation

Abdominal surgery within the last 6 months

Your Personal Details

Your best phone number

Emergency Contact Details

Reason for appointment

What is the main area of focus or motivation for your session?

Do you have a primary concern?

Menstrual and Fertility History

Please tick any that apply

Excessive bleeding more than one tampon or pad per hour

Polycystic Ovarian Syndrome

Premature Ovarian Failure

Have you ever taken contraception drugs?

Are you undergoing Artificial Reproductive Treatment for infertility?

Symptoms experienced prior to and during menstruation. Please tick any that apply:

Constipation/Diarrhoea

Pain/Numbness in left leg

Dark thick blood at beginning of menstruation

Dark thick blood at end of menstruation

Heaviness or pressure in lower pelvis

Symptoms or conditions you are currently experiencing. Please tick any that apply:

Varicose Veins Left leg

Varicose Veins Right leg

Difficulty experiencing orgasms

Difficulty breathing into abdomen

Pregnancy/Birth History

Have you ever been pregnant?

Have you experienced:

What are your feelings toward birth, regardless of whether you have given birth or not?

Please tick any that apply:

Abdominal pain left side

Abdominal pain right side

Your Medical History & Considerations

Please tick any that apply:

Surgery on your abdomen or lower back

Accidents or traumas

Falls or injuries to tailbone, sacrum or head

Recent procedures in the last 6 months

Are you currently taking medications? Please provide details below:

Do you have any sensitivities or allergies to oils or essential oils?

Do you have any other allergies?

Emotional & Spiritual (the following four questions are optional, however completing this gives an overall understanding of where you are at)

What is your opinion of your self?

What hobbies/activities provide you with the most pleasure and accomplishment?

What changes would you like to see/experience in the next 6 - 12 months?

Please use this space to add any further comments if you feel to.

Is there anything else I need to know to ensure your comfort and safety during your appointment time? (optional)

I consent to be emailed post-session information after the massage. I acknowledge that this will also add me to Kate's mailing list to receive updates of any news, offers and upcoming events. Note: You will be able to unsubscribe at any time.

Yes, I consent to receive post-session information and occasional updates

Consent & Declaration

Please tick EACH statement below to show your agreement before signing

I declare that the information I have provided on this form is, to the best of my knowledge, true and accurate, and that I have not intentionally withheld any information relevant to my treatment. I will inform Kate Dillon of any changes to my health status.

I understand that Womb & Fertility Massage is not a replacement for medical care and does not diagnose, treat, or guarantee outcomes for any medical, physical, or mental health condition.

I understand that Womb & Fertility Massage does not guarantee pregnancy.

If I experience any pain or discomfort during the session, I will immediately inform Kate Dillon so that the pressure and/or technique may be adjusted to my level of comfort.

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent to receive treatment.

By booking, I agree to Kate Dillon's Cancellation & Late Arrival Policy: https://katedillon.net/policies/

Womb & Fertility Massage ~ Client Intake Form

Contraindications

Please note the following is contraindicated to receiving the full Womb & Fertility Massage Treatment. If any of the below apply to you, please tick so the treatment can be adjusted accordingly.

Your Personal Details

Emergency Contact Details

Reason for appointment

What is the main area of focus or motivation for your session?

Do you have a primary concern?

Menstrual and Fertility History

Please tick any that apply

Have you ever taken contraception drugs?

Are you undergoing Artificial Reproductive Treatment for infertility?

Symptoms experienced prior to and during menstruation. Please tick any that apply:

Symptoms or conditions you are currently experiencing. Please tick any that apply:

Pregnancy/Birth History

Have you ever been pregnant?

Have you experienced:

What are your feelings toward birth, regardless of whether you have given birth or not?

Digestive History

Please tick any that apply:

Your Medical History & Considerations

Please tick any that apply:

Are you currently taking medications? Please provide details below:

Do you have any sensitivities or allergies to oils or essential oils?

Do you have any other allergies?

Emotional & Spiritual (the following four questions are optional, however completing this gives an overall understanding of where you are at)

What is your opinion of your self?

What hobbies/activities provide you with the most pleasure and accomplishment?

What changes would you like to see/experience in the next 6 - 12 months?

Please use this space to add any further comments if you feel to.

Is there anything else I need to know to ensure your comfort and safety during your appointment time? (optional)

Email Communication

I consent to be emailed post-session information after the massage. I acknowledge that this will also add me to Kate's mailing list to receive updates of any news, offers and upcoming events. Note: You will be able to unsubscribe at any time.

Consent & Declaration

Please tick EACH statement below to show your agreement before signing

Sign your agreement below:

Date