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1 Name: Date of Birth: / / Today s Date: / / General Information Yes No Yes No Are you now or could you be pregnant? Do you have a pacemaker, heart Date of conception arrhythmia, or other heart condition? Do you have a history of miscarriage? Have you ever had blood-clotting problems Have you ever been diagnosed with or problems with bleeding? Hepatitis? Are you on blood thinning medications? HIV? Do you take aspirin regularly? AIDS? TB? If so, when? How would you describe your overall general health now? Poor Fair Good Excellent How has your health been most of your life? Poor Fair Good Excellent Do you have any chronic health problems or diagnoses, (such as anemia, high cholesterol, high blood pressure, hypoglycemia, gastrointestinal problem, etc.)? Please include date diagnosed and all current and past treatment. Prescription Medications Please list any non-fertility prescription medications you are currently taking and what they are for: Vitamins/Supplements Please list any vitamins or other supplements you are taking: Surgical History Please list all surgeries and approximate age: Allergies Specific allergen and reaction: Major Accidents/Injuries Please list any major accidents (include head injuries, fractures, deep cuts, serious sprains, etc.) Indicate date or age: Family Medical History Please indicate any illness/disorders that have occurred in your immediate family (include parents, siblings, and grandparents) Diabetes Cancer High Blood Pressure Heart Disease Stroke Other Fertile Ground Wellness Center Female Fertility Intake Form
2 Sleep Please describe your sleep: Hours per night Do you wake most nights? Do you have trouble falling asleep? Do you feel refreshed when you wake up? Do you use medication for sleep? If so, do you wake at the same time each night? If so, what kind and how often? Emotional/Cognitive Do you experience an emotion/pattern often or excessively If so, which emotions/patterns? Anger Fear Worry Sadness/Grief Joy Depression Cry Easily Frustration Mood-swings Poor memory Easily irritable Foggy thinking Explosive outbursts Difficulty making decisions Obsessive/repetitive thinking Tendency to hold things in If you experience mood-swings, are they related to eating/not-eating? If you are female and have mood-swings, are they related to your menstrual cycle? Stress List major stressors in your life: On a scale of 0 (no stress) to 10 (freaking out), how do you rate your overall daily stress level? How would you rate your level of happiness in life (scale of 1-10, 10 being the highest): How would you rate your level of happiness in your job (scale of 1-10, 10 being the highest): Energy Levels Check all that apply: Are you fatigued or do you fatigue easily Do you regularly have a low-grade fever Do you need to take naps Does your sweat have a strong odor Do you generally feel cold Do you ever wake up sweating at night Do you have cold feet and/or hands Do you perspire easily without exertion Do you catch colds frequently Do you feel tired after meals Do you have energy slumps at certain times of day Do you have excess/nervous energy Do you wake up tired in the morning Does your energy pick up after you get up Do you feel energized after exercise and move about in the morning Appetite and Digestion Check all that apply: Has your appetite changed lately Do you have intestinal gas Do you have a poor appetite Do you experience a bitter taste Are you hungry all/most of the time Do you have acid regurgitation Do you feel foggy or low if you miss a meal Do you crave particular foods Do you have abdominal (intestinal) bloating Sweet Salty Do you experience belching/hiccups Bitter Sour Do you have heartburn Hot or spicy Do you have gurgling sounds in your intestines Do you experience bad breath Do you have a nervous stomach Fertile Ground Wellness Center Female Fertility Intake Page 2of 7
3 Nutrition/Diet Information Please describe your appetite Strong Normal Poor Do you hunger quickly? Please describe your diet (low fat, low-carb, vegetarian, etc.) Please list what you ate yesterday Breakfast: Lunch: Dinner: Snacks: How much water do you drink per day? What is your drinking water source? Tap Bottled Filtered Reverse osmosis Distilled Well Other fluids _ Please describe your thirst Strong Normal Poor Exercise Do you exercise regularly? Please describe type & frequency/week Other Are you presently taking steroids? Was your mother exposed to diethylstilbestrol (DES) when she was pregnant with you? Have you been exposed to any known environmental toxins or hormones? Complimentary Health Care List any previous complimentary health care that you have participated in: Last visit date Practitioner/Reason for care Treatment ongoing Acupuncture Massage Therapy Chiropractic Care Naturopathic Care Hypnotherapy Other Fertile Ground Wellness Center Female Fertility Intake Page 3of 7
4 Fertility History How long have you been trying to conceive? Is there a history of difficulty conceiving or pregnancy loss in your family? Fertility History Pregnancies Births Miscarriages Terminations Ectopics D&C Abnormal Pap Smear Dates Fertility Treatments Have you had fertility treatments? Start Date (Month/Year): If yes, are you being treated by: RE & I Clinic/Fertility Specialist: RMFC CCRM FCC Conceptions CU Albrecht Women s Care Which doctor are you seeing at this clinic? Other OBGYN doctor Have you had a diagnosis related to fertility? Western Diagnosis Your Diagnostics Date Your Diagnostics Date Elevated FSH Low Progesterone Level Uterine Fibroids/Polyps PID Endometriosis/Adhesions Chlamydia PCOS Herpes POF Other STD s: Antisperm antibodies Other diagnostics: Fertile Ground Wellness Center Female Fertility Intake Page 4of 7
5 Fertility Medications Have you taken medication to help you ovulate? When? How long? If you have been diagnosed with PCOS, are you taking Glucophage How long? Fortamet How long? Are you taking extra B-Complex vitamins? Procedures performed Dates Results Laparoscopy HSG (Hysterosalpingogram) PI (Pulsatility Index) Have you had any tubal operations? Lab Tests Dates Results FSH Level Day 3 HCG Prolactin TSH T3 T4 Free T4 Free T3 OAR Estrogen Progesterone Testosterone Cholesterol Triglycerides Others: Fertile Ground Wellness Center Female Fertility Intake Page 5of 7
6 Fertility Treatments (including cancelled cycles): Date Natural, IUI, Medication used # of mature eggs Pregnancy If miscarried, lvf, other /follicles Yes/No what week? Future ART Plans Date Date IUI w/ injectables IVF IUI w/ oral meds PGD Clomid Other: Reproductive Health When did your last period start? What day of your cycle are you on today? At what age did menses begin? Do you have regular pap tests? Are you currently charting your menstrual cycles (BBT charting)? Do you receive or give yourself regular breast exams? Do you douche regularly? Do you use vaginal lubricants? Do you use tampons? How is your sexual energy? High Normal Low None Are you experiencing any sexual problems? If yes, please explain: Please give the following information about your periods. How many days are there between one period and the next? How many days do your periods last? Yes No Yes No Is your period regular? Headaches before your period? Are your periods painful? Headaches after you bleed? Do you bleed excessively? Tightness in your chest? Do you bleed too little/scanty? Do you have low backache? Do you discharge clots? Do you tend to sigh a lot? Fertile Ground Wellness Center Female Fertility Intake Page 6of 7
7 Describe menstrual flow: Heavy Moderate Light None Color of menstrual flow: Dark Bright red Slightly reddish Brown (at beginning/end) Clotting (mark as appropriate): Bright in color Brown/grainy Stringy Dark in color Size of clots: Dime Nickel Larger Cramping (mark as appropriate) Where are your cramps? Low back Groin area Down legs When do you feel them? Before period During period During ovulation Severity of cramps Mild Moderate Severe Do you use pain medication? What kind of medication? PMS 10 days before 1 week before 2-3 days before Breast tenderness Depression Loose stool Constipation Fatigue Low back pain Facial break-outs Cravings Bloating/water retention Irritability Other: Do you have a history of: Amenorrhea Menstrual cramps Ovarian cysts Failure to ovulate Ectopic pregnancy Pelvic Inflammatory Disease Endometriosis Painful intercourse Uterine fibroids Irregular periods Chronic vaginal or yeast infections Vaginal discharge Bleeding between periods Contraception History Method Length of time used How long ago? Length of time used How long ago? Pills Patch (Ortho Evra) Diaphragm Shot (Depo-Provera) Condoms Partner Information Partner s Name Has your partner had a fertility workup? IUD Vaginal ring (NuvaRing) Rhythm method Fertility Awareness Other: Western Diagnosis of your partner Is your partner supportive of your wish to conceive? Does your partner experience any sexual dysfunction? Please list all vitamins, herbs, medications that your partner is currently taking: Fertile Ground Wellness Center Female Fertility Intake Page 7of 7
Lucas D. Brown, L.Ac. (312)
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