Holistic Fertility Health History Form
Please have your spouse/partner complete his/her own form.
Date
*
/
Month
/
Day
Year
Client Name
*
Spouse/Partner's Name
*
Client Phone Number
*
Client email
*
Client Birthday
-
Month
-
Day
Year
Date
YOUR PHOTO (LEFT SIDE)
*
Browse Files
Cancel
of
YOUR PHOTO (FRONT)
*
Browse Files
Cancel
of
YOUR PHOTO (RIGHT SIDE)
*
Browse Files
Cancel
of
Type of Visit?
*
Initial consultation
Follow-up
Lifestyle
Believe it or not, this is important!
List of colors you like:
*
List of colors that you DO NOT like:
*
What are your "go to" spices:
*
List of spices you DO NOT like:
*
List of music genres you like:
*
List of music genres you DO NOT like:
*
Organization
*
Does everything have its own place?
Are things organized in containers or boxes?
No organization at all?
Organized piles?
Countertops & Table Tops
*
Things can be scattered about?
Nothing is to be on the countertops?
Constantly wiped down?
Not wiped down?
Floor
*
Must constantly be swept/mopped?
Not concerned with the floor?
Prefer carpet?
Prefer wood?
Prefer tile?
Prefer brick/stone?
Your feet:
*
Shoes always?
Socks only?
Barefoot as often as possible?
Fertility
How long have you been trying to have a baby?
*
Less than 1 year
1 - 3 years
More than 3 years
How many times have you been able to conceive?
*
How many pregnancies resulted in a baby?
*
How many miscarriages?
*
Do you have biological children?
*
Yes
No
Number of children and their ages?
i.e. 4 - 3,7,9,10
At the beginning of your menstrual cycle, what color is the blood?
Brown
Pink
Bright Red
Other
How long does your cycle last?
Fill in the number of days
Type of menstrual flow?
Extremely light
Light
Medium
Heavry
Varies
Do you see ovulation mucus?
Yes
No
Sometimes
Not Sure
Have you or your partner gone through any fertility testing?
*
Yes
No
Please list any details
When having sex, do you and your partner need to use an external lubrication?
*
Yes
No
Sometimes
Do you experience orgasms?
*
Yes
No
Sometimes
How often are you having intercourse?
*
About Your Skin
This tells us a lot about your internals, so the more you share the more it will help!
Acne
Red and inflamed on the surface
Red and inflamed, stuck under the surface
Small clogged under the surface (congestion)
Small clogged on surface (whiteheads)
Blackheads
Bloody
Pus
Age Reversal
Lines and wrinkles
Sagging
Loss of elasticity
Lack of luster
Jowls
Under eye bags
Under eye discoloration
Pigmentation
Hyper
Hypo
Melasma
Age spots
Liver spots
Dry skin
Dry
Flaky
Oily skin
Oily all over
Oily in t-zone
Dewy
Scarring
Red
White
Silver
Pitting
Elevated
Keloids
New
Old
Eczema
Exact Location(s)
How frequently are you experiencing eczema?
Constant eruption
Intermittent
How long have you been experiencing eczema?
Visible Capillaries
Yes
No
If capillaries are showing is there also redness in the area?
Yes
No
Location of Visible Capillaries
Nose
Cheeks
Chin
Other
Rosacea
Bumps
No Bumps
Location of Redness
Nose
Cheeks
Chin
Psoriasis
Exact Location(s)
How frequently are you experiencing psoriasis?
Constant eruption
Intermittent
How long have you been experiencing psoriasis?
Uneven Skin Tone
Yes
No
Client Home Care
Please list the skin care and body products you are currently using including brand names.
*
Does you experience any sensations/symptoms etc. when using any of your skin care products?
Yes
No
If yes, please explain.
Are you currently under that care of a physician, if so please list the details.
*
Emotions
Is the tip of your nose typically red?
*
Yes
No
Is there usually a red spot on the middle of your chin?
*
Yes
No
Sleep
How much sleep do you get?
*
At least 7 hours per night
Less than 7 hours per night
Do you wake up during the night at specific times:
9pm - 11pm
11pm - 1am
1am - 3am
3am - 5am
5am - 7am
7am - 9am
9am - 11am
11am - 1pm
1pm - 3pm
3pm - 5pm
5pm - 7pm
7pm - 9pm
Stress Level
How is your stress level?
*
1 Low
2
3 Medium
4
5 High
What is your chosen method for relieving or handling your stress?
*
Exercise
Yell
Stay quiet
Meditate
Listen to music
Go for a drive
Punch or throw things
Take deep breaths
Other
Foods and Drinks
Foods (80% or more)
*
Hot
Warm
Cooked
Raw
Cold
Frozen (ice cream)
Processed
Fresh
Do you eat salads?
*
Yes
No
How often do you eat salads?
*
Do you drink smoothies?
*
Yes, No Ice Added
Yes, Ice Added
No
Do you juice?
*
Yes
No
Do you drink protein shakes and/or eat protein bars?
*
Yes
No
Protein Shakes or Bars
*
Vegan based
Animal based
Vegan and Animal Based
Milk and Milk Alternatives
*
Regular Milk
Almond
Coconut
Soy
Other
Do you eat fresh fruit?
*
Yes
No
How often do you eat fresh fruit?
*
List the fresh fruits you like
*
List the fresh fruits you DO NOT like
*
List the vegetables you like
*
List the vegetables you DO NOT like
*
How do you prepare most of your meals?
*
Raw
Stovetop
Oven
Grill
Sauté or Stir Fry
Air Fryer
Instapot
Do you eat meat?
*
Yes
No
Is your meat grass fed?
*
Yes
No
Are your eggs free range/cage free?
*
Yes
No
What kinds of meat do you eat?
*
Beef
Bison
Deer
Chicken
Turkey
Fish
Shrimp
Oysters
Crab
Lobster
Clams
Mussels
Which do you prefer?
*
White meat
Dark meat
Both
If you eat red meat, how do you prefer to have it cooked?
*
Well done
Rare
Medium
Do you eat sushi?
*
Yes
No
DAILY WATER INTAKE (Are you drinking 50 - 70% of yourr body weight in ounces?)
*
Yes
No
Sometimes
Which types of water do you drink?
*
Tap water
Filtered tap water
Spring water
Purified water
Alkaline water
Distilled water
Flavored-naturally
Flavored-artificially
Well Water
Sodas
*
Sugar
Diet
Sodas - How often? How Much?
*
Energy Drinks
*
Sugar
Diet
Energy Drinks - How often? How much?
*
Coffee
*
Hot
Cold
Caffeinated
Decaffeinated
Artificial Flavors
Coffee - How often? How many cups?
*
Tea
*
Hot
Cold
Caffeinated
Decaffeinated
Herbal
Tea - How often? How many cups?
*
Examples of Typical Meals
Breakfast
*
Lunch
*
Dinner
*
Snacks
*
Drinks
*
Meditation / Breathing Techniques
Do you meditate or have breathing techniques that you do daily?
*
Yes
No
Movement
Do you exercise or participate in sports on a daily or weekly basis?
*
Yes
No
Where do you workout?
*
Home
Outside
Gym
Which type of exercise?
*
Walk
Yoga
Pilates
Stretching
Running
Sports
Weight training
Tai Qi
Qi Gong
Martial Arts
Other
Are any of the exercises you participate in done in a room or outside above 90 degrees? (Example yoga or pilates performed in the hot sun)
*
Yes
No
How often do you workout?
*
How long are your exercise intervals?
*
Less than 30 minutes
More than 30 minutes
Do do you work up a sweat?
*
Yes
No
Sometimes
Daily Dose of Sunshine
How much real sun do you get per day, without sunglasses or sun protection?
*
Less than 30 minutes
More than 30 minutes
Health History
Current or Past Health Concerns
Do you experience any of the following:
*
Hot or Cold hands or feet
Joint pain/stiffness
Grind teeth
Thinning hair
Full head of hair
Reproductive issues
Quality of fingernails
Quality of teeth
Birth Control Methods-current and previous
*
Birth control pills
Implants
IUD
Tubal
Vasectomy
Hysterectomy
Post Menopausal
None
Other
Current Medications and Purpose
*
Current Supplements or Vitamins and Purpose
*
Do they contain any silica / cellulose / yeast / sugar / fillers / binders / color / artificial ingredients?
*
Yes
No
Do you have any allergies?
*
Food related
Environmental
Other
Digestion
*
Constipation more than once per month
Diarrhea more than once per month
Bloating
Gas (upper or lower)
Acid reflux
Stomach aches
History of Digestive Disorders (IBS, Crohns, etc.)
Bowel Movements
*
Daily
Not Daily
Smell Bad
Minimal to no smell
2-3 inches long
Hard and small like pebbles
Loose or Liquid
Does it leave marks in the toilet after flushing?
Urine
*
Deep yellow or orange
Slight yellow tint
Clear
No smell
Smells like fish
Less than 6 times per day
More than 6 time per day
Do you leak or have trouble making it to the toilet?
Submit
Should be Empty: