Lisa Fabry Qigong & Yoga Therapy
Client Information Form
General Health: Women
Please fill out this form and press SEND at the bottom of each section to submit. All information is confidential and it will be stored securely.
Name
Today's date
Date of birth
Address
Email
Phone number (inc country and area code)
Occupation
Emergency contact
Other medical practitioners you see
Health fund
Do you have any current medically diagnosed conditions or injuries?
What are your three main health goals?
Has your weight increased or decreased in the last year?
Please describe what kind of exercise you currently do eg walking 15 mins/day, yoga class, dancing etc
Do you have any kind of meditation or self-reflection practice?
Please list all medication you take, including prescribed drugs, over-the-counter medicines and supplements.
Have you ever experienced a hypersensitivity reaction to any medication or remedy?
Do you have any known allergies or sensitivities?
FAMILY HEALTH HISTORY
Father
Mother
PERSONAL HEALTH HISTORY
PLEASE DESCRIBE ANY SYMPTOMS YOU CURRENTLY HAVE
Digestive
Immune
Breathing
Urinary
Skin
Músculo-skeletal
Headaches
Mental health
Sleep
Stress
Anything else not mentioned?
Please list any significant events in your life, which could have impacted your health.
Send
WOMEN: Reproductive and Sexual Health
Age of menarche (first period)
Do you currently have a menstrual cycle?
If you do currently have a menstrual cycle:
Are your periods regular or irregular?
How long is your usual cycle?
How many days does your period last?
Anything that concerns you about your menstrual cycle?
If you do not currently have a menstrual cycle:
When was your last period (approximately)?
How many pregnancies have you had?
Have you had any miscarriages/ terminations?
When was your last Pap smear?
When was your last breast exam?
Are you currently sexually active?
What kind of contraception are you using?
Do you suffer from UTIs or yeast infections?
Do you have experience of the following:
premenstrual headaches
bloating
breast tenderness
weight gain in midsection?
Do you have any concerns about your sexual health?
Send
lisa@lisafabry.com
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Name
Email
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