Fertility Questionnaire for Women
To help us serve you, the more information we have the better!
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Date
-
Month
-
Day
Year
Date
Email
example@example.com
Have you had Acupuncture before?
How serious are you? What is your comittment level to get pregnant?
Have you had previous pregnancies, Miscarriages? How many full term?
How long have you been trying?
Are you also pursuing Western Treatments?
Do you have a Western Diagnosis?
Do you have any allergies to supplements/ foods/ herbs?
How much do you weigh?
How tall are you?
If so, what treatments, medicines are you on, if any?
Have you had a hormone panel? Menvue or been checked for blockages?
If you have had blood work or any western diagnoses, please upload them here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
What is your age?
Are you on supplements? Herbs? Vitamins?
Have you been pregnant before? If so when?
If you have been pregnant? How was the pregnancy, birth?
Quality of sleep: how long? wake up rested? do you wake up? what times? Do you urinate at night?
Do you have injuries, chronic pain? Where? Surgeries? Head injuries?
Are you willing to do a Basal Body Temperature Chart?
If you have a BBT chart, please upload here at least three months worth, if possible.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
How is your digestion? Constipation, loose stools? IBS? Dietary restrictions? Food intolerances?
How many times do you urinate a day?
How many times do you have a BM a day?
Are your stools soft, firm, pellets, color?
What foods do you crave if any? Or tastes, sweet, salty, bitter?
Do you run hot or cold?
Are parts of your body warm ? or cold?
Do you have hot flashes or night sweats?
What is an example of what you eat for the day?
What is your period like? Cramps? PMS? Breast Tenderness? Heavy flow? Clots? How many days? How long is your cycle?
Submit
Should be Empty: