Fertility & Reproductive Health Intake
What is your birth date and age?
What are your main concerns? Fertility, menstrual disorder, hormonal imbalance, painful sex, incontinence, menopause, other?
Do you have any allergies? If yes, please list them
Have you been in a car accident? If yes, what year and how bad the accident was.
Have you had any falls that bruised your tailbone or hit any part of your hip/ pelvis?
What sports have you played beginning from childhood? Please list each sport and age.
Have you been diagnosed with fibroids, endometriosis, PCOS, adenomyosis, or other? Please describe
Have you used birth control pills to regulate your periods, prevent pregnancy or another reason? How many years?
Have you used other forms of birth control? If yes, please describe
Have you experienced miscarriages or other losses? If yes, how many? Feel free to give details.
Do you have children? If yes, what ages?
Have you had one or more C-Sections?
Have you had other surgeries in your abdominal area? If yes, please describe and give dates.
What was your first period like? How old were you? What was the pain level, amount of bleeding, emotions, etc.
How often do you get your period?
Do you use tampons, pads, menstrual cups, or cloth pads? What brand?
What physical symptoms do you experience the week leading up to your period?
What emotions do you experience the week leading up to your period?
Do you experience constipation before or during your period?
Do you experience incontinenc or frequent urination before your period?
Describe Day 1 of your period 1.Pain level 1-10 and duration of pain. What medication do you take? How often? 2. Describe Blood color and texture. 3. Amount of bleeding/ how often you need to change you pad/ tampon.
Describe Day 2
Describe Day 3
Describe Day 4
Describe each remaining day of your period.
How often do you get up to urinate at night?
Do you notice any physical symptoms when you ovulate? If yes, please describe.
Do you experience yeast infections? How often? What triggers it? What do you use to heal?
Do you get bladder infections? How often? What triggers it? What do you use to heal it?
Is sex painful? Do you have difficulty reaching orgasm with intercourse? Please describe
Do you have spider veins or varicose veins? Where are they?
Do you have cold hands/ feet?
Have you used clomid?
Have you used fertility acupuncture? If yes, when?
Have you tried IUI? How many times?
Have you tried IVF? How many times?
Are you getting ready for follicle stimulation, egg transfer or IVF?
Do you know your AMH and FSH numbers? What are they?
Do you have an autoimmune disease or a medical condition?
What medications do you currently take?
What vitamins, minerals or supplements do you currently take?
How often do you have bowel movements?
Do you have digestive issues? If yes, please describe
What type of diet do you have? Eg. vegetarian, paleo, keto, live on fast food, etc.
Is there something else I should know?
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