Pulling Down the Moon Mayan Abdominal Massage Intake Form ...

Pulling Down the MoonMayan Abdominal Massage Intake Form (Male)(Please Print Clearly)Date :____/_____/_____Full Name: ____________________________________________Date of Birth:___________________________Address:__________________________________City:___________________State:________Zip:___________Gender:_______Age:_________Height_______Weight:____________Email:____________________________Home Phone:_____________________ Cell Phone:__________________ Work Phone:___________________Occupation:_____________________________Employer:____________________________________________Emergency Contact Name:______________________ Emergency Contact Phone:_______________________How did you hear about us? (doctor, nurse, office staff, flyer, postcard, PDtM website, other website,friend, tv, magazine, internet search) please specify:_______________________________________________Primary Care Physician Name and practice location:_______________________________________________OB/GYN or Urologist Name and practice location: ________________________________________________Reproductive Endocrinologist Name and practice location:_________________________________________In case of a Press Event, would you be willing to share your story? (circle one) YES NOIf YES, please circle which of the following we could contact you about:Paper/Print Interview Television Radio Testimonial

FAMILY HISTORYAlive? Age/Cause of Death Major Health IssuesMother:______________________________________________________________________________Father:_______________________________________________________________________________Siblings:______________________________________________________________________________Family History of Abuse_______ circle if applicable: physical emotional sexual spiritualFamily History of Substance Abuse_______ Suicide__________ Other Trauma_____________________DIGESTION & ELIMINATIONTypical Breakfast:_____________________________________________________________________Typical Lunch:_________________________________________________________________________Typical Dinner:________________________________________________________________________Snacks:_________________________ Water Intake(glasses/day)________ Caffeine________________Do you experience bloating/gas/burps after eating?____ What foods trigger this?_____________________How often are your bowel movements? ______________ Do your stools: sink______float_______Constipation?_______ Blood in stool?_______ Mucus in stool?__________ Pain when stooling?_________Other concerns________________________________________________________________________EMOTIONAL & SPIRITUALWhat is your opinion of yourself?__________________________________________________________If possible, please describe the most negative emotion you experience_______________________________When do you most often feel this emotion:__________________ Where are you?____________________Do you pray to or have a spiritual practice___________________________________________________On a scale of 1 – 10 ( 1 being the lesser, 10 the greater) Please rate yourself:Faith______ Hope________ Charity_______ Generosity_________ Sense of Humor____________Sense of Fun_____________ Fear_________ Grief________ Sadness ___________Other (describe briefly)________________________________________________________________What are hobbies/ activities that provide you with a sense of pleasure and accomplishment___________________________________________________________________________________What changes would you like to achieve in 6 months__________________________________________One Year____________________________________________________________________________MEDICAL HISTORYAre you currently under the care of another health care provider(s)?__________Reason (s)___________________________________________________________________________________________________

Name(s) of Practitioner __________________________________:_______________________________Phone_______________________________________ email_________________________________Current Medications: ____________________________________________________________________Allergies: specify allergen and reaction:_____________________________________________________Supplements/Remedies_________________________________________________________________Surgical History (year and type)________________________________________________________________________________________________________________________________________________Recent Procedures:_____________________________________________________________________Hospitalizations ___________________________________________________________________________________________________________________________________________________________Accidents or Traumas_________________________________________________________________Falls/Injuries to Sacrum/head/tailbone (describe)____________________________________________Birth Trauma if known _________________________________________________________________Do you use Tobacco?______ Quantity _____/ppd Alcohol? ______ Quantitiy ____ounces/ dayMarijuana?____ Quantity____ Other:__________________Have you been under treatment for substance use?If so, describe:_________________________________________________________________________Circle any of the following you are Currently experiencingUnderline and of the following you have experienced in the PastAsthmaAnxietyDepressionFainting SpellsTrouble SleepingLoss of MemoryRinging in EarsPainful JointsSwollen JointsSwollen anklesSinus ConditionsSeizuresSciaticaFrequent Colds/ Upper RespiratoryconditionsHigh or Low Blood PressureCold Hands or FeetPins and needles in arms, legs,hands or feetDenturesContact lensesArtificial /Missing limbsHeadaches: migraine, tension,fatigue, clusterSpinal ProblemsHerniated or Bulging disc:(location)________________Muscular Tightness:(location)_______________________Skin Disorders: Acne, Fungus,Psoriasis. Location:______________________Other:___________________________________________________________________________MALE ~ REPRODUCTIVE HEALTH HISTORYCheck and Describe those symptoms as applicableSore heels_______________ Numb/achy/antsy legs or feet________________________Low back pain______________ Difficulty sitting for long periods _______________________

Varicose Veins _____ Locations_____________________________________________________Family History of Prostate Disease:_______Type______________________________________________ Relationship______________________Family History of Cancer__________________Type______________________________________________ Relationship______________________History of sexually transmitted disease____________When_________Type___________________________Rate your interest in Sex:High___________Moderate____________Low____________None_________________Do you have or ever had difficulty experiencing orgasms________________________________________Have you experienced a history of rape_______ trauma_______ incest_______If so,-when___________________________________________________Did you undergo counseling for this________________________________________________________What was this like for you________________________________________________________________Urinary Symptoms (circle those applicable)Painful urination Bladder/Kidney infectionsFrequent Urination Nocturnal Urination/ Frequency________Changes in urinary stream (describe flow, stream, strength of stream)___________________________When did you first notice these symptoms_________________________________________________Are they getting better or worse? Describe: _________________________________________________Erectile Function (describe as indicated)Difficulty obtaining an erection Difficulty maintaining an erection Painful ejaculationIs there a history of back injury/trauma______Describe:____________________________________________________________________________When did you first notice these symptoms___________________________________________________Are they getting better or worse? Describe__________________________________________________Current Medications or Supplements:____________________________________________________________________________________________________________________________________________Results of PSA (prostate specific antigen) Test if known__________________ Date done______________Results of Sperm count (if applicable and known)_______________________ Date done____________Additional Comments:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please read and signI understand that payment is due at the time of treatment unless arrangements have beenmade other wise. I agree to give at least 24 hours notice of cancellation of appointment.Cases of extreme emergency are considered exceptions to this cancellation policy. Iunderstand the treatment here is not a replacement for medical care. I understand thetherapist/practitioner does not diagnose medical illness, disease or any other physical ormental conditions (unless specified under his/her professional scope of practice). As such,the therapist/practitioner does not prescribe medical treatment of pharmaceuticals, nor doeshe/she perform any spinal manipulations (unless specified under his/her professional scopeof practice). I understand that the treatment is not a substitute of medical treatments and/ordiagnosis and it is recommended that I see a qualified professional for any physical or mentalconditions that I may have. I have stated all my known conditions and take it upon myselfto keep the therapist/practitioner updated on my health.Client signature_________________________________________ Date_____________Therapist/Practitioner signature:____________________________ Date_____________

Addendum to New Patient IntakeRelease of Information FormI understand that my doctor may be made aware that I am participating in Pulling Down theMoon programming and/or services:Name Signature DateFrom time to time, Pulling Down the Moon may find it necessary or helpful to discuss some ofthe details of your case or treatment with your medical team. By initialing below you authorizePulling Down the Moon to review your case with your medical doctor and/or nurses._______ (Your Initials) I authorize Pulling Down the Moon to correspond or speak with mymedical doctor or nurse.My Physician’s Name/s and practice(please print)_________________________________________________________________