Date of Appointment

Name

Email Address

Phone No

Date of Birth

Your Age

Your Occupation

Marital Status

Referred By

Are you presently having any massage/bodywork, if so, what type?

What is your primary concern?

Are you currently under the care of a health care provider(s), if so, please give details:

Current Medications/Supplements/Remedies:

Any Accidents or Trauma (year & type)?

Falls/Injuries to Sacrum/head/tailbone (describe):

Birth Trauma (if known):

What is your typical breakfast?

What is your typical dinner?

What is do you snack on?

What processed food do you eat?

How much water do you drink?

How much coffee do you drink?

How much alcohol do you drink?

Do you experience bloating/gas/burps after eating?

Which foods trigger this?

How often are your bowel movements?

Do your stools sink/float?

Do you ever suffer from constipation?

Have you experienced any of the following in the past or are currently experiencing: Have you experienced any of the following in the past or are currently experiencing: Ringing in Ears Pins and Needles in arms, legs, hands, or feet Loss of Memory Depression Asthma Swollen Ankles Sinus Sciatica Fatigue Trouble Sleeping Muscular Tightness Herniated or Bulging Disc High or Low Blood Pressure Other None of the above

Do you suffer headaches? (explain)

Do you suffer back pain?

Do you have sore heals?

Varicose Veins? (if so, where?)

Family History of Prostate? (Disease? Type? Relationship?)

Family History of Cancer? (Type? Relationship?)

History of sexually transmitted disease? (when, type?)

Your Interest in Sex .. 1 to 5? (1 being none / 5 being high)

Do you have or ever had difficulty experiencing orgasms? Do you have or ever had difficulty experiencing orgasms? Yes No Sometimes

Urinary Symptoms? Urinary Symptoms? Painful Urination Bladder/Kidney Infections Frequent Urination Nocturnal Urination Other None

Changes in Urinary Stream? (Describe flow, stream, strength of stream)

When did you first notice these symptoms?

Is it getting better or worse

Do you have difficulty obtaining an erection? Do you have difficulty obtaining an erection? Yes No Sometimes

Painful ejaculation? Painful ejaculation? Yes No Sometimes

When did you first notice these symptoms?

Are they getting better or worse? If so please describe...

Is there a history of back injury/trauma? If so please describe...

Results of PSA Test (prostate-specific antigen), if known & date done...

Results of Sperm Count, if applicable & date done...

Other information that might be helpful

What is your opinion of yourself?

If possible, please describe the most negative emotion you experience...

Have you ever experienced or witnessed emotional or physical abuse?