Client Initials:
Age:
Case Study Number:
Primary Reason for Visit? *
When did you first notice it? *
What brought it on? *
Describe any stressors occurring at the time: *
What activities provide relief? *
What makes it worse? *
If yes, please provide details:
If yes, please provide details:
If yes, please provide details:
If yes, please provide details:
If yes, what type?
If Yes, please give reason(s):
Practitioner Phone Number:
Practitioner E-Mail Address:
If yes, please state what you are on:
If yes, please state specific allergen and reaction:
If yes, please list year and type of surgery and/or recent procedures:
If yes, then please list:
If yes, then please list:
If yes, please give full details:
If yes, please give full details:
What is your opinion of yourself? *
If possible, please describe the most negative emotions you experience: *
When do you most often feel this emotion? *
Where are you when you feel this? *
If yes, please provide details:
If yes, please describe briefly:
What hobbies or activities do you have that provide you with a sense of accomplishment? *
Describe your exercise routine (type, frequency): *
What changes would you like to achieve in 6 months? *
Changes in one year? *
When did you first begin your menses? *
What was this experience like for you? *
How many pregnancies have you had? *
Number of Deliveries/Dates? *
If yes, When?
If yes, When?
If yes, please state:
What was your experience of pregnancy?
What was your experience of labour?
What was your experience of delivery?
What was your experience post partum?
If yes, please state these:
Any birth trauma if known? *
If yes, please state:
If yes, please state:
If yes, which one?
If yes, please state:
Length of time using method?
When was your last cervical smear? *
If yes, please describe your treatment:
If yes, please describe the treatment you received:
If yes, please describe:
What were the results if known?
Length of menses? *
If yes, please state when and for how long?
Please give details:
If yes, please give details:
Gynaecological care provider if known?
If yes, please describe:
What was this like for you?
Any additional comments: