ALL INFORMATION GIVEN IS STRICTLY CONFIDENTIAL. YOUR INFORMATION ...
ALL INFORMATION GIVEN IS STRICTLY CONFIDENTIAL. YOUR INFORMATION WILL NOT BE SHARED WITH ANYONE<br />First Name: ___________________________________ Last Name: __________________________________________<br />Address: _________________________________________________________________________________________<br />Cell Phone: ______________________________ Home Phone: _____________________________________________<br />Email: ___________________________________________________________________________________________<br />Check here is you would like to receive our monthly newsletter ____<br />Emergency Contact Name and Phone Number ___________________________________________________________<br />How did you hear about our clinic? _____________________________________________________________________<br />Reason for today’s visit? _____________________________________________________________________________<br />Medical HistoryAge:_____ yrsDate of Birth: ________________Weight: __________kgsHeight:________Sm<br />Have you had any major illnesses or surgeries?DateIllness/SurgeryHospitalizationTreatment/Outcome<br />List all medications you are taking. Include ones you use occasionally such as inhalers or allergy medicationNameDoseReason for taking it<br />List all vitamins or herbal supplements you are takingNameDoseReason for taking itDo you have any allergies? If so, to what? _________________________________________________________________________________________________________________________________________<br />Do you have, or have had, any of the following illnesses or diagnoses?Arthritis __Asthma __Anemia __Cancer __Diabetes __Gallstones __Hepatitis A B CHeart Disease __High Blood Pressure __HIV+/AIDS __Hypothyroid __Hyperthyroid __Kidney Stones __Seizures __Stroke __<br />Are you on blood thinners? YES/NODo you have a pacemaker? YES/NOFor Women OnlyAre you currently pregnant? YES/NO**Please inform your practitioner as soon as you know you are pregnant as this may affect treatment**Menstrual HistoryAre you in menopause?YES/NOHysterectomy/Ovaries removed?YES/NOEven if you are in menopause, please fill out the following information as this can help with diagnosis.<br />Date of last period: _________________Age of first period: ______ yrs<br />Are your periods regular? YES/NONumber of days from start of one period to start of next one: _________<br />Average days of flow: _____ daysAre your cramps MILD PAINFUL SEVERE <br />Indicate for each day how many tampons or pads you use, the color of the blood. If you use painkillers, indicate on which day you use them and the doseNo. of Tampons/Pads?Color of Blood? Eg. Light red, red, dark red, purple, brown, black, watery, thin, pinkishPainkillers? How many? Over the counter or prescription?Day 1Day 2Day 3Day 4Day 5 <br />Are the cramps better with heat? YES/NODo you see blood clots in the flow? YES/NODo you experience spotting before your period begins? YES/NO<br />Do you experience any of the following prior to your period or as your period begins?Water retention __Irritability __Migraines __Food cravings? For sugar or salt? ______<br />Bloating __Breast tenderness__Low Back Pain__Break outs __<br />Crying spells __Anger or Rage __Anxiety or Depression __Do you get dizzy or light headed around your period? YES/NO<br />Do you experience breast tenderness/pain around the middle of your cycle? YES/NO<br />Do you spot or bleed between periods?YES/NODo you know when you ovulate?YES/NODo you chart your cycle? YES/NODo you have fertile (egg-white consistency) cervical mucus around ovulation time? YES/NO<br />Do you experience any discharge during your cycle? YES/NODo you get frequent yeast infections? YES/NO<br />Have you ever had any of the following?Pelvic Inflammatory Disease (PID) __Chlamydia __HPV __Genital Herpes __Do you have any nipple discharge? YES?NO<br />Have you ever had an abnormal Pap smear? YES/NOIs there a history of sexual abuse? YES/NOAre you using or have you used any of the following types of contraceptives?<br />Birth Control Pill __From age ____ to ____DepoPrevara __From age ____ to ____IUD __From age ____ to ____<br />Do you have endometriosis? YES/NODo you have PCOS? YES/NODo you have fibroids or polyps? YES/NOIf so, how many and what size?Do you have any auto-immune disease such as lupus, rheumatoid arthritis? If you are seeking help with fertility, please go to the section FOR FERTILITY PATIENTS to answer these questions in the chart provided. If you are NOT a fertility patient, please answer the next four questions below.Have you ever been pregnant? YES/NONo. of children?No. of abortions?No. of D&Cs?<br />Men Only Please check all that applyPremature Ejaculation ___Erectile dysfunction ___Dribbling urine ___Varicocele ___Genital Herpes___Genital Warts ___Other STDs ___<br />For Fertility Patients (Men & Women)How long have you been trying to conceive?Have you consulted your OB/GYN or Urologist? YES/NO<br />Name of Urologist or OB/GYN: ____________________________________________________________________Have you seen a Reproductive Endocrinologist (fertility doctor)? YES/NOName of Fertility Doctor? ________________________________________________________________________May I discuss your treatment with your RE? YES/NOHave you been given a fertility diagnosis? __________________________________________________________Test ResultsFSH Level: ______Estrogen Level: _____Progesterone: _____Antral Follicle Count: _____AMH Level: _____<br />Have you had a hysterosalpingogram (HSG) YES/NOIf yes, were there any findings?<br />Sperm count (million per mL)___________________Eg. 15 (20) million per mLMotility (in %)___________________Eg. 40+%Morphology (in %)_________________Eg. 3+%<br />List all pregnancies and fertility treatments below:<br />DateNatural/Clomid/IUI/IVFMedicationsNo. of follicles retrievedNo. follicles fertilizedNo. of follicles transferredPGY/NIf miscarried, indicate at what week<br />General Health Questions <br />Do you eat breakfast in the morning? YES/NO<br />Do you eat fresh fruits? How many times a day? 0 1 2 3 4<br />Do you eat fresh vegetables? How many times a day? 0 1 2 3 4<br />Do you cook your own meals? Yes/NO/Sometimes<br />Cups of coffee a day? 0 1 2 3 4+<br />Cigarettes a day? 0 ½ pack 1 pack 1+ pack Only smoke socially<br />Alcohol a week? 0 1 2 3 4 5+ <br />How many times a week do you exercise? 0 1 2 3 4 5 6 7<br />Circle all that you do: Walk Run Aerobics Lift Weights Yoga Other<br />SleepAny problems falling asleep? YES/NOAny problems staying asleep? YES/NOHow many hours do you get a night?Are you rested in the morning? YES/NODo you have sleep apnea? YES/NO<br />Please check all that apply below. If you NEVER experience a symptom, leave blank.<br />1 = In the past<br />2 = A few times a year <br />3 = A few times a month <br />4 = A few times a week<br />5 = All the time <br />1234512345Lower back pain or weakness or knee problemsRinging in your ears or dizzinessNight sweatsProne to hot flashesAre you afraid a lotHigh sex driveLow sex driveFearful or shy of new situationsWake up at night or early in the morning to urinateUrinate frequentlyUrgent, loose stools in the morning Profuse vaginal dischargeFeeling cold in generalCraving SaltCold feet, especially at night1234512345FatiguePoor appetiteEnergy lower after a mealFeel bloated or uncomfortable after eatingCrave sweetsLoose stoolsCold hands and feetFeel heavy or sluggishBruise easilyPoor circulationFeel heavy or groggy in the headVaricose veinsLack strength in arms or legsObsessive thoughts/worryingLow blood pressureSweat a lot without exertionDizzy or lightheaded or visual changes when you stand upOften sick or allergiesHemorrhoids1234512345Dry flaky skinChapped lipsBrittle fingernailsBrittle or dry hairDiminished nighttime vision<br />1234512345Emotional DepressionProne to anger and/or rageHeartburnDifficulty falling asleepFeel better after exerciseTight feeling in chestDifficulty taking a deep breathPeople tell you that you sigh a lotDry or red eyesAlternating diarrhea/constipationSymptoms worse with stressNeck/shoulder tensionFloaters in visionFeeling of heat rushing to headFrequent headaches1234512345Wake early in the morning and have trouble getting back to sleepHeart palpitations especially when anxiousNightmaresInsomniaLow in spirit lacking in vitalityProne to agitation or extreme restlessnessFidgetSweat excessivelySores in mouth1234512345Spontaneous sweatFeeling of sadness or deep griefAllergiesUnable to let goCatch colds easilyAsthmaFeel tired after exerciseShortness of breathGeneral weaknessCoughNasal dischargeDry nose/mouth/skin/throatSinus congestionThirst for cold drinks most of the timeFeel warmer than those around youWake up sweating <br />