Fertility Intake Form For women trying to get pregnant naturally or wanting to improve their chances of success with IVF / IUI / FET First Name Last Name Email Mobile Phone Birth Date Gender Female Male Relationship Status Single Married Divorced Widowed Ages of children Occupation Height Weight Have you ever had acupuncture before? No Yes How did you hear about us? Friend/Relative Doctor Google Facebook Lecture Other Name of doctor or friend that referred you (if applicable) How long have you been wanting to become pregnant? Less than 6 months 6-12 months 1-3 years More than 3 years Check any diagnosis you've received from a fertility specialist: Blocked tubes Diminished ovarian reserve Endometriosis Fibroids High FSH PCOS Poor egg quality Premature ovarian failure Recurrent miscarriages Unexplained infertility Uterine abnormalities Check any treatments you've done so far: Acupuncture Donor eggs/embryos IVF (In-vitro Fertilization) IUI (Intrauterine insemination) Nutrition/Functional medicine Oral medication (Clomid/letrozole etc) Other List medications, supplements you're taking (or enter "none" if none) If you're receiving fertility treatment, tell us the doctor's/practitioner's name: Check all tests/procedures you're aware of that have been perfomed within the last 12 months AMH levels FSH/LH levels Proactin levles Thyroid/TSH Hysteroscopy HSG (xray with dye to check tubes) Laparoscopy Ultrasound of uterine cavity Ultrsound of ovaries Number of pregnancies Partener's semen analysis results Not tested Poor Good Excellent List any major injuries, accidents, or surgeries and when they took place (or enter "none" if none) Anything else you think we should know about your fertility situation/journey? Check all in your FAMILY HIstory Arthritis Anxiety Asthma Autoimmune Disease Bowel issues Cancer Chronic skin conditions Depression Diabetes Dementia Hypertension Heart Attack Stroke Liver Disease Kidney Diseas Ulcer Osteoporosis/Ostopenia STP HIV/AIDS Infertility Check all in YOUR history Arthritis Anxiety Asthma Autoimmune Disease Bowel issues Cancer Chronic skin conditions Depression Diabetes Dementia Hypertension Heart Attack Stroke Liver Disease Kidney Diseas Ulcer Osteoporosis/Ostopenia STP HIV/AIDS Infertility List known food or drug allergies (or enter "none" if none): Energy level is generally Very low Low Normal High Very high Check all that apply Energy fluctuates a lot during the day Frequent sleepiness after meals Sudden burst of Energy in the evening Very tired in the moring Mood is generally Sad Irritable/angry I'm pretty chill Excited/upbeat Worried Anxious/nervous Any mood issues (check all that apply) Anger control issues Anxiety Bipolar Depression Panic attacks Weight Stable Recent Gain Recent loss Body temp sensation often feel warm/hot Often feel cold/chilled Fluctuates Stable/Normal Check all that apply Cold hands and feet Frequent sweating Hot flashes Night sweats Warm Hands and feet Bowel Habits 1-3x daily More than 1-3x daily 3-5x per week Less than 3x per week Check all that apply for digestion/bowel movement Acid reflux Bloating/gas Celiac/gluten sensitivity Constipation Cramping/urgency Fullness after meals Hemorrhoids IBS Indigestion Loose stool Sleep is: Terrible Not great Pretty good Awesome Check all that apply to sleep: Difficult to fall asleep Difficult to stay asleep Difficult to wake up Restless sleep Nightmares Wake up and difficult to fall back asleep Wake up earlier than desired Wake up to urinate multiple times Bedtime Wake time Number of times you wake during the night Check all that apply: Allergy/sinus issues Carbohydrate Cravings Concussion Chronic cough Dizziness/lightheadedness Ear/hearing problems Eye problems Fainting Frequent colds/flu Frequent headaches/migraines Heart palpitations/irregular heartbeat Joint/spinal problems Low blood pressure Loss of taste/smell Muscle weakness/soreness Nails soft or break easily Shortness of breath Swelling in legs or feet Age of onset of menstruation Age of onset of menopause (if applicable) Date last period started Cycle length (e.g. 28 days, 27-35 days) Length of period flow (e.g. 4 days, 5-7 days) Cramping None Mild Moderate Severe Color of flow Normal red Dark Red Pale red Black Other Flow amount is Normal Light Heavy Extremely light Extremely Heavy Check all that apply: Lots of clots Lots of tissue Mid-cycle Bleeding/spotting Spotting prior to period Spotting more than 2 days after end of period Tired during/after period Severe mood swings before or during period Do you ovulate regularly Yes No Not sure Cervical mucus with ovulation is Normal Scanty Excessive Absent Not sure/don't check If you track ovulation - how? (check all that apply) Basal body temp (BBT) Ovulation predictor kit App on my phone Don't track Other Anything else you want us to know about your cycles / period / ovulation Describe time and types of foods you eat for breakfast (e.g. eggs, oatmeal, 7am) Describe time and types of foods you eat for lunch: (e.g. salad, sandwich, 12 noon) Describe time and types of foods you eat for supper (e.g. chicken, rice, vegetables 7 pm) Describe time and types of snacks you eat: Submit
