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Health & Fertility Questionnaire
Please complete the following before your first appointment. All information you provide is confidential and won't be shared with anyone without your written request.
Name
*
First
Last
Date of Birth
*
Partner's Name
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
Phone
*
How old were you when you had your first period?
*
How frequently do your periods come (i.e., every 28-30 days)?
*
Do you experience cramping with your periods?
*
Yes
No
If yes, is it:
*
Mild
Moderate
Severe
Do you take pain medication for menstrual cramps?
*
Yes
No
Specify type and amount of pain medication:
*
Do you bleed or spot between periods?
*
Yes
No
If yes, please describe:
*
Have you ever had an abnormal Pap smear result?
*
Yes
No
If yes, what year(s) and what therapies were used?
*
When was your last Pap smear? (If you are due for one, we can provide this service - indicate your interest)
*
Have you ever had any of the following infections? Check all that apply.
*
Chlamydia
Gonorrhea
Trichomonas
Herpes
Genital warts
HPV
Bacterial Vaginosis
Pelvic inflammatory disease
Syphilis
None of the above
If you checked any of the above, please note the treatment(s) received and when (year).
*
Do you have pain with sex?
*
Never
Sometimes
Frequently
Always
Do you now have or have you had in the past any of the following in your reproductive tract?
*
Ovarian cysts
Endometriosis
Fibroids
Polyps
None of the above
If yes to any of the above, please give details (dates, treatments, outcomes):
*
Did your mother take DES when she was pregnant with you?
*
Yes
No
Not sure
Have you used contraception in the past?
*
Yes
No
If yes, note the type(s) and dates of use:
*
Will this be your first cycle trying to conceive?
*
Yes
No
If not, how long have you been trying and by what method(s)?
*
Have you been charting your cycles?
*
Yes
No
If yes, for how long?
*
What elements do you record? Check all that apply.
*
Basal body temperature
Ovulation predictor kit
Fertility monitor
Ovulatory sensation
Mucus changes
Ferning of saliva
Other
If you have been using urine ovulation predictors, what brand and how many times per day do you test?
*
Have you seen a doctor or other provider (acupuncturist, naturopath, midwife, etc.) specifically for fertility?
*
Yes
No
If yes, please note date(s):
*
If you have had any lab tests or diagnostic procedures done, please list dates and whether there were any abnormal findings.
*
Upload copies of lab reports if available:
*
Max file size: 20MB
Upload File 2
*
Max file size: 20MB
Upload File 3
*
Max file size: 20MB
Are you taking herbs or fertility drugs? If so, please list:
*
Are your cycles being monitored with ultrasound?
*
Yes
No
Have you been treated for infertility previously?
*
Yes
No
If yes, please indicate where, when, diagnosis, treatment and outcomes:
*
Do you have an account set up with a sperm bank?
*
Yes
No
If yes, which one(s)?
*
Have you ever been pregnant? (including elective terminations, miscarriages, births)
*
Yes
No
If yes, please note dates and outcomes of each pregnancy:
*
Do you have or have you ever had any of the following? Check all that apply:
*
Anemia
Thyroid imbalance
Diabetes
Kidney problems
Liver problems
Gallbladder disease
Arthritis
Seizures
High blood pressure
Chronic headaches
Neurological problems
Clotting disorders
Autoimmune disease (e.g. Lupus, HIV, MS)
Cystic Fibrosis
Cancer
None of the above
If you checked any above, or if you have experienced other health conditions not listed, please provide details of dates, treatments and outcomes:
*
Have you had any surgeries (gynecological or other)?
*
Yes
No
If yes, please note dates, type of surgery, findings of surgery:
*
Have any of these problems occurred in your family?
*
High blood pressure
Diabetes
Heart disease
Thyroid disease
Ovarian cancer
Breast cancer
Infertility
Other
Indicate the family relationship to you for any conditions checked above:
*
What age was your mother at menopause?
*
If you have sisters, please detail their reproductive history:
*
Do you smoke cigarettes?
*
Yes
No
If yes, how many cigarettes/packs per day?
*
If you smoked in the past, when did you quit?
*
Do you drink alcohol?
*
Yes
No
If yes, how many drinks per week?
*
Have you noted any significant weight change in the last year?
*
Yes
No
If yes, please describe how many pounds gain or loss and over what time period:
*
Describe your daily nutrition, including any dietary restrictions:
*
Do you exercise regularly?
*
Yes
No
If yes, indicate type of exercise and number of hours per week:
*
If you are allergic to any medications, latex or foods, please indicate the substance and type of reaction:
*
If you are currently taking any prescription drugs, over-the-counter medications, supplements or herbs not listed above, please indicate by name, dose and reason for use:
*
Is there anything else you would like to share with us about you or your preferences which can help us provide sensitive, thoughtful care appropriate to your situation?
*
Whom may we thank for referring you?
*
Submit
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