Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Phone *

(###)

###

####

Regular menstrual cycles? *

Yes

No

N/A

Have you ever experienced sexual abuse? *

Yes

No

Do you experience any anxiety? *

Yes

No

Womb Hara Contra-Indications - please tick any that currently apply: *

IUD/fitted coil

Abdominal or pelvic surgery

Possibility of pregnancy

Actively trying to conceive or IVF

Currently on your menstrual cycle

Within 2 days of your next menstrual cycle?

Postpartum bleeding

None

Menstrual & Fertility History - please tick any that apply: *

Painful periods

Painful ovulation

Irregular periods

Heavy bleeding

Fibroids

PCOS or PCO

Endometriosis

Miscarriage

Fertility issues

None

N/A

Have you ever been pregnant? *

Yes

No

N/A

Medical History - please tick any that apply: *

Abdominal, pelvic or lower back surgery

Accidents or trauma

Falls or injury on your sacrum, tailbone, neck or head

None

Digestive History - please tick any that apply: *

Constipation

Diarrhoea

IBS

Abdominal pain

Organ issues

Painful areas

Bloating

None

Are you open to receiving ginger Moxibustion? *

Yes

No

Unsure