Consultation Form - Fertility Massage

Personal Information
Name *
Reasons for Visit
Does this intefere with:
Menstrual and Fertility Conditions
Painful Periods
Painful Ovulation
Irregular Periods
Excessive Bleeding
(>1 pad/tampon per hour)
PCOS (Polycystic Ovarian Syndrome)
Polycystic ovarian syndrome, or PCOS, is a condition in which a woman's levels of the sex hormones estrogen and progesterone are out of balance. This leads to the growth of ovarian cysts (benign masses on the ovaries). PCOS can cause problems with a women's menstrual cycle, fertility, cardiac function, and appearance.
PCO (Polycystic Ovaries)
PCO disease is an hormonal problem that causes women various symptoms including: Irregular or no periods Acne Obesity, and Excess hair growth.
Many women are unaware they have fibroids because they don't have any symptoms. Women who do have symptoms (around one in three) may experience: heavy periods or painful periods tummy (abdominal) pain lower back pain a frequent need to urinate constipation pain or discomfort during sex
POF (Premature Ovarian Failure)
Premature ovarian failure (POF) is when a woman's ovaries stop working before she is 40. POF is different from premature menopause
Failure to Ovulate / Low Ovulation
The failure of the ovary to release an egg at the appropriate time in the menstrual cycle.
Anti-Müllerian Hormone, or 'AMH' as it is often called, is a hormone which is given off by developing follicles, which are egg sacs containing immature eggs.
Symptoms experienced Prior to and during Menstruation
Lower Back Ache
Change in bowels
e.g Constipation/Diarrhoea
Pain/Numbness in Leg
Dark thick blood during Menstruation
Blood clots
Heaviness of pressure in lower pelvis
Dragging Sensation
Increased Urination
Symptons Currently Experienced
Varicose Veins
Bladder Infections
Bladder Weakness
Frequent Urination
Cold Hands or Feet
Anxiety / Depression
Trouble with Sleep Onset
Trouble with Sleep Maintenance
Tightness in Chest
Difficulty Breathing into Abdomen
Digestive Complaints
(<1 per day)
Formed Bowel Movements
Sausage Like
Hard Bowel Movements
Non-Formed Bowel Movements (pellets)
Abdominal Pain
Medical History
Are you under treatment for infertility i.e IVF
Have you had any surgery?
Have you experienced Accidents or Traumas?
Have you experienced injuries?
Recent procedures
(<6 months) - if yes give detail below
High/low blood pressure
Other relevant medical conditions
If yes give detail below
Menstrual & Pregnancy History
E.g. Natural, Water Birth, Epidural/Pethidine, Forceps/Ventouse, C-Section
Other Events
please read and confirm
You confirm your understanding that i) Cancellations within 24 hrs incur a 50% charge ii) Treatment is not a replacement for medical care iii) we do not diagnose medical illness or any other physical or medical conditions and iv) we do not prescribe medicines. *
You confirm you have stated all known conditions *
You agree to advise us of any updates to the above. *