Bellibind Intake FormsMedical Information Sheet Name First Name Last Name Are you taking any medications? * Yes No If Yes, please list name and use: How many days postpartum are you? Any risk factors? Do you suffer from chronic pain? Yes No If yes, please explain What makes it better? What makes it worse? Have you had any surgerie? Yes No If yes, please list: Please indicate any of the following that apply to you. Cancer Headaches / Migraines Diabetes Infant Loss High/Low Blood Pressure Blood Clots Numbness Explain any conditions you have marked above: Thank you!
