Holistic Fertility Health History Form

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) *

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Cancel of
YOUR PHOTO (FRONT) *

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Cancel of
YOUR PHOTO (RIGHT SIDE) *

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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
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?
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
Rosacea

Bumps No Bumps
Location of Redness

Nose Cheeks Chin
Psoriasis
Exact Location(s)
How frequently are you experiencing psoriasis?
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:
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
Foods and Drinks
Foods (80% or more) *
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
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 *
Sodas - How often? How Much? *
Energy Drinks *
Energy Drinks - How often? How much? *
Coffee *
Coffee - How often? How many cups? *
Tea *
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
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? *
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? *
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
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
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?
Should be Empty:

Holistic Fertility Health History Form

Lifestyle

Fertility

About Your Skin

Client Home Care

Emotions

Sleep

Stress Level

Foods and Drinks

Examples of Typical Meals

Meditation / Breathing Techniques

Movement

Daily Dose of Sunshine

Health History