Nature's Organic Touch
Fertility Intake Form
Name
*
First Name
Last Name
Name of partner
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Date of birth
*
-
Day
-
Month
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you been trying to conceive?
*
Which treatments have you done
*
Hysterosalpingogram (HSG) Test
Medicated Follicular Study
IUI
IVF
Embryo Genetic testing
Ovarian Drilling
Cyst / Fibroid removal
Other
Any supplements/alternative treatment you have tried ?
*
Have you ever had a vaginal steam before?
*
Yes
No
When was the first last day of your period?
*
Please mark any of the following that apply
*
Yes
No
Painful Periods?
Painful Ovulation?
Failure to ovulate?
Dark blood at the end or beginning of cycle?
clotting?
lower back pain with cycle?
bloating?
Excessive bleeding?
Heaviness in pelvic with period?
Irregular cycle?
Irregular Ovulation?
Spotting?
Pms /Depression/irritability?
Headaches /Migrains with periods?
PCOS?
Endometrosis?
Experiencing hot flashes ?
Digestive issues?
Difficult / painful incomplete urination ?
Painful intercourse ?
Pelvic Pain ?
Pain in genital area ?
Low libido ?
Rectal Pain ?
Uterine Fibroids ?
Vaginal Dryness ?
Womb Trauma ?
Cancer-Eps of the reproductive area?
Are you past ovulation ?
Have you gone under any fertility treatment ?
Are you prone to bacterial vaginosis ?
Are you prone to yeast infections ?
Are your menstrual cycles currently or historically ever 27 days or shorter?
Have you experienced any hot flashes in the past month ?
Are your menstrual cycle 28 days or longer ?
Is your menstrual cycle absent or missing for an unknown reason or because of birth control ?
Genetic issues
Miscarriage
Male factory inventory
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