pre-visit form

Name

Email Address

Your Relationship With Care

Have you ever had a wellness or gynecological visit before?yesno

How was that experience for you? (choose any that apply)It felt safe and supportedIt was okay—not great, not terribleI felt rushed or not fully seenI felt anxious or overwhelmedIt was physically painful or uncomfortableIt was emotionally difficult or triggeringI’ve had both positive and hard experiencesI’m not sure how to describe itI’d rather not say

Have you ever had a pelvic exam or pap smear?yesnoI don’t remember

Would you like to include a pap smear during this visit?yesnoI’m not sure yet

Have you ever had a breast exam?yesnoI don’t remember

Would you like to include a breast exam during this visit?yesnoI’m not sure yet

Your Needs & Boundaries

Is there anything in your medical or personal history you'd like me to be aware of that could affect how you experience care?

Are there any touch points that feel especially vulnerable or activating for you?

Are there specific words or phrases you’d prefer I do or don’t use when we talk about your body?

Your Preferences

How would you like to be approached during the visit? (choose any that apply)I prefer clear step-by-step explanationsI like to know everything ahead of timeI prefer minimal talking once we beginI’d like grounding practices (breathwork, oils, etc.)I’m not sure—let’s feel it out together

Do you have a support person you'd like to bring to your visit?yesnoI’m not sure yet

Anything else you’d like me to know?

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