New Patient Fertility Form (Women)

Bodyscapes Fertility Form (Women)

Please complete all eleven sections of this form (20-25 minutes). If at any time you wish to save and continue filling out this form at a later time, click "Save" (located at the end of each section). A Jotform pop-up box will appear to get your email address. You will be emailed your form to complete at your convenience.
1. General Information
Name (first):
(last):
Date of Birth:

Month Day Year
Age:
Address

Street Address

Street Address Line 2

City State

Zip Code
Home Phone:
Cell Phone:
Email Address:
example@example.com
Emergency Contact (name and phone number):
How did you hear about Bodyscapes?

Internet Doctor Referral Ad Event Word‐of‐Mouth
Reason for seeking treatment:
Are you currently going through Assisted Reproductive Therapy (ART)?

No Yes
Type of therapy:
Have you gone through any Assisted Reproductive Therapies in the last few years?

Yes □ No
Please specify:

11. Diet
How is your appetite?
How many meals per day do you eat?
How often do you have a bowel movement?
Are you thirsty?
Daily water intake:
Do you prefer hot or cold beverages?
Do you drink caffeine? How much per day?
List other beverages you drink including juice, rice milk, almond milk, soy milk, tea, etc:
What dairy products do you eat?
Are you a vegetarian or vegan?
List sources of meat/protein:
What % of your diet is organic?
Do you have any particular cravings?
List any food allergies or sensitivities:
Do you eat regularly at fast food restaurants?
Times per week you eat out?
Do you eat a lot of processed food?
Do you eat late at night?
Do you think you get enough fresh fruits, vegetables, and whole grains daily?
Do you drink alcohol? How much?
Do you smoke cigarettes?
Do you take any other recreational drugs?
How would you describe your diet?

Unhealthy Fair Good Fantastic
How would you rate your cooking skills on a scale of 1 to 10 (10 being best)
Are you ready and willing to make changes in your diet if need be?
Thank you for completing this form.

All information will be kept confidential.

Please click "Submit" when completed.
Should be Empty:

	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7
Color of menstrual blood (bright red, rust, pale, etc,)
Amount of Flow (heavy, medium, light)
Clots (large, small, dark, purple, red)
Cramps (mild, medium, severe)
Pain (low back, ovaries, headache, etc.)
Bloating (check if yes)
Nausea (check if yes)

Bodyscapes Fertility Form (Women)