Acupunctureincharlotte.com

Acupuncture & Natural Healing
Women’s Fertility History
Name_______________________________________Date______________________ How long have you been trying to conceive? _____ □ Months □ Years Have you received a Western Medical diagnosis? □ No □ Yes, please explain: ______________________________________________________________________Age of menarche: ____ Date of last menses: __________ Cycle length: __________ Painful periods? □ No □ Yes How many days does the pain last? _____ # of days of bleeding: ____ Flow strength: □ Light □ Normal □ Heavy Color of blood? □ Light Red □ Red □ Dark Red □ Purple □ Brown □ Black Are your cycles: □ Regular (i.e. every 28-30 days) □ Irregular, please explain: _____________________________________________________________________ Spot between periods? □ No □ Yes – every month? □ No □ Yes Do you experience PMS? □ No □ Yes: □ Breast Tenderness □ Irritability □ Emotional □ Bloating □ Low Back Pain □ Loose Stools □ Constipation □ Nausea □ Headaches Number of: Pregnancies _____ Abortions _____ Miscarriages _____ Children _______ Have you had a D& C: □ No □ Yes – how many times? _____ Date of last Pap Smear: ________ Abnormal Pap Smear? □ Present □ Past Have you ever had: □ Cervical Biopsy □ Cauterization □ Conization □ Operation Have you had your fallopian tubes evaluated? □ No □ Yes, when? _______________________________ Venereal Disease? □ No □ Yes - □ HPV □ Herpes □ Other: _____________________ Vaginal Discharge? □ No □ Yes - □ Clear □ White □ Yellow □ Pink □ Brown □ Copious Vaginal dryness? □ No □ Yes – have you been diagnosed with Vulvodynia? □ No □ Yes Yeast Infections? □ No □ Yes - □ Every once in awhile □ Frequently □ Every month Have you been diagnosis with: □ PID □ Uterine Fibroids □ Polyps □ Pelvic Adhesions □ Endometriosis □ Other: _____________________________________________________________________ Do you experience pain with intercourse? □ No □ Yes - □ sometimes □ every time Do you find it difficult to achieve an orgasm? □ No □ Yes - □ sometimes □ every time Is your libido: □ Low □ Average □ High Do you ovulate? □ No □ Yes – what day of your cycle? ______ Have you used Clomid? □ Past □ Present How are you tracking your ovulation? □ Ovulation test kits □ Basil Body Temps □ Cervical Fluid □ Fertility testing □ Other: _________________________________________________ Have your menstrual cycles changes since they first began? □ No □ Yes – Please explain: ______________________________________________________________________ Are you currently under the care of a fertility clinic? □ No □ Yes, please name physician and clinic: _____________________________________________________________ Have you or are you currently or do you plan to have fertility treatments? □ No □ Yes, please list any past, current or future treatments and dates: _________________________________________________ Please indicate any tests you have completed and dates (or approximate month and year): Test Result Date
Surgeries/Procedures: Please list any gynecological surgeries or procedures: Procedure:
Reason For:
Date Performed:
Medications: Please list past medications used specifically for gynecological conditions, including contraceptives: (please list any medications for infertility purposes in the next section) Medication: Prescribed
For: Dates
Please list medication used specifically for fertility treatments: Medication: Prescribed
For: Dates
Have you ever had an IUD? □ No □ Yes, currently □ Yes, in past from _______ to_____ Have you ever taken Depo Provera? □ No □ Yes – when? ________________________ I understand that I am providing details of my fertility history to Acupuncture & Natural Healing for informational purposes only. Licensed Acupuncturists are not Primary Care Physicians and while Acupuncture supports the fertility process, it does not replace standard medical care. Acupuncture has been well documented to increase and assist couples with their fertility process and I have provided complete and accurate information to Acupuncture & Natural Healing so that the practitioners can provide the best care possible. Signature_____________________________________Date______________________ 

Source: http://www.acupunctureincharlotte.com/wp-content/uploads/2012/03/WomensFertilityHistory.pdf