Full Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Why are you interested in Abdominal/Pelvic work? *

check all that apply

Period problems

Hormone Health

Pelvic Issues

Preconceptionion

Fertility

Connection to Self

Pelvic Floor issues

Bladder Issues

Scar tissue

Other

Have you scheduled your appointment yet? *

Yes

No

Please list current health providers, including MDs, DOs, specialist, chiropractors, bodyworkers, etc.

Do you smoke cigarettes?

Yes

No

Sometimes

Cycle Health

Your cycle starts on day 1 of your period, and ends the day before your next period. Tell me about yours:

I'm not cycling because of birth control

I'm not cycling because of breastfeeding

I'm menopausal

I have cycles under 24 days

My cycles are between 24-35 days

I have really long cycles

My cycles are all over the board

My cycles are consistently irregular

I go a long time without a period and I'm not sure why

I stopped taking birth control and my period hasn't returned

Menstrual Blood

Menstrual blood can give a lot of information about health. Can you tell me more about what you see?

Spotting before period starts

Dark blood at beginning of period

Clots

Heavy bleeding

Dark Blood at end of cycle

Start, stop for a day, then resume bleeding

Flooding (changing pad/tampon/cup once an hour)

Current forms of birth control *

Please check all that you are currently using,

None

Abstinence

Track Cervical Fluid

Track Temperature

Pills

Patch

Nuva Ring

Depo Shot

Arm Implant

Copper IUD

Hormonal IUD

other

Period Symptoms

Do you experience any of the following symptoms while on your period, or just before?

Bloating

Breast Pain

Headaches

Migraine

Mood Swings

Cramping

Spotting

Low back pain

Pain in legs /heels

Mid-cycle spotting

Pain with ovulation

Are you aware you have any of the following? *

please check all that apply

Anemia

Endometriosis

Uterine or Cervical Polyps

Vaginal Infections (BV, yeast, trich, etc)

Bladder Infections

Episodes of Amenorrhea (not having a period)

Fibroids

Cysts

PCOS

Metabolic Resistance

Pelvic Congestion

Laparoscopy scars

C- Section Scar

Abdominal surgery scar

Bladder prolapse

Uterine Prolapse

Rectal Prolapse

Hemorrhoids

Varicose Veins

Umbilical Hernia

Hiatal Hernia

Acid Reflux

Constipation

Diarrhea

Bladder Symptoms

Do you experience any of the following bladder symptoms?

Frequent Urination

Can hold bladder for a long time

Incontinence (can't hold bladder)

Can stop urine flow

Can't stop urine flow

Trouble beginning to pee

Painful urination

Urinary Tract Infections

Interstitial Cystitis

Interest in Sex? *

High

Moderate

Low

None

Can you experience orgasms? *

Yes

No

Name *

First Name

Last Name

Have you scheduled your appointment yet? *

Yes

No

Approximately when are you due? *

MM

DD

YYYY

Are you in a supportive relationship?

Yes

No

Do you have a Doula? *

Yes

No

Do you have a postpartum Doula? *

Yes

No

I understand that Chloe does not physically turn breech babies, but can gently create space for them to turn on their own. She also has other resources, just ask! *

Yup, Got it!

Your name *

First Name

Last Name

Have you scheduled your appointment yet? *

Yes

No

If yes, provide the date scheduled

MM

DD

YYYY

How was your baby born? *

check all that apply

Vaginally

C-section

Epidural

Forceps

Vacuum

Short labor

Long labor

Stuck

Do they prefer one boob?

Right

Left

No preference

Do they stay latched?

Yes

No

Are your nipples sore or shredded?

Yes

No

Do they poop every day?

Yes

No

Are they fussy?

Yes

No

Sometimes

Do you have someone to relieve you?

Yes

No

Name *

First Name

Last Name