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Initial Health History Form

Hello.
I am Carine Camara a licensed acupuncturist and owner of Pelvis Wellness, a center in Lafayette, CA focused on your reproductive and sexual health. I’m the developer of the Pelvis Wellness Method™, which is the utilization of acupuncture, abdominal therapy and hands on energy healing in transformative sessions. I’m passionate about helping you improve your quality of life, so that you can focus on fulfilling your goals and, if desired, growing your family.

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Step 1 of 14

7%

How do you feel about the weather?*
- I dislike the heat
- I dislike the cold
- I dislike humidity and/or damp foggy conditions
- I dislike dry climates

How do you drink your water?*
- Iced, Chilled
- Lack of thirst and/or drawn to warm or hot
- Not thirsty
- Takes frequent sips of room or warm temperature

What are your food cravings?*
- Cold, Cooling foods. Ice cream, please.
- Warm, spicy foods. Pass the hot sauce.
- Fried foods, dairy, carbs. Yes, to baked goods.
- Sugary Foods. Hmmm...chocolate

How would you describe your skin?*
- Red, botchy, acne
- Pale
- Puffy, red acne, or clammy, eczema, psoriasis
- Ashen, red checks, dry
- Normal for me.

Which emotional state do you identify with?*
- Quick to anger, easily irritated
- Fatigue, depressed, insecure
- Mental Fog, Fatigue, Heavy feeling in the body
- Irritable, tense, anxious

How are your bowel movements?*
- Hard, difficult to pass, constipation
- Diarrhea
- Loose stools, mucus or blood in stool
- Small hard pebbles, dry, constipation
- Regular, daily, no issues

How would you describe your self?*
- Friendly, Open, Charismatic
- Curious, Bright, Introspective
- Nurturing, Supportive, Relaxed
- Organized, efficient, disciplined

How do you Sweat?*
- Sweat a lot and easily
- Difficulty Sweating
- Perspires often and constant or feel clammy
- Night Sweats, sweaty hands and feet

How do you Sleep?*
- Restless, disturbing dreams
- Oversleep- always tried
- Snores, difficultly breathing, not restful
- Insomnia, wakes up hot at night
- Great

Which best describes your Appetite?*
- Voracious appetite, eat large portions
- Low. Slow metabolism
- Lack of appetite, abdominal bloating and fullness
- Eats often, gets agitated if meals are missed

Which symptoms best describe your chronic imbalances?*
Please choose the option that has one or more of your symptoms. Or the options that is relatively close to your current health condition.
- Frequent headaches, migraines, heart burn, stomach pain
- Sinus congestion, stiff painful joints, pain in low back or knees, fatigue
- Chronic yeast infections, headaches, bladder infections, fluid retention in joints, little to no energy
- Dry cough, dry eyes, hot flashes
- None of these apply.

How would you describe your body?*
Choose the option of your current body or issues you had in the past.
- Average, Can tend to be overweight, larger about the abdomen
- Difficulty losing weight, retains water, flabby muscles
- Overweight, excess fat, puffy, retains water
- Slender, thin, average, difficult losing weight in abdomen

How do you feel about temperature in your living room?*
- Loves a cool to cold room. AC, fans, windows. Constant cool air flow
- Tends to like a room warm and cozy. Has lots of throw blankets, and loves fireplaces and heaters.
- Tend to like either warm or cold. Likes freshness, needs the room to have no dampness or humidity.
- Has cold hands and feet, yet gets hot in the afternoons, or wakes up at night hot and sweating. Needs to be able to adjust the temperature when needed.

Great Job Completing the Questionnaire! Enter your first name and your email. You will get a PDF sent to your mailbox on the best foods for your body type.
Name*
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Location

936 Dewing Avenue, Suite B

Lafayette, CA 94549

Tel: 925 310 5317
e:hello@pelviswellnessmethod.com

Carine happily serves the surrounding areas Walnut Creek, Moraga, Orinda, Danville, Oakland, Berkeley, San Francisco

Hours of Operation

By Appointment Only

Monday – Friday 10 – 7pm

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