Cycle At A Glance - wholehealthcenters.com · Incontinence White Yellow Green Hemorrhoids Lack of...

© The Fertility Cure, LLC. 2007 1

Important: Complete this document as thoroughly as possible. Some questions may seem unrelated to your condition, but they may affect yourdiagnosis and treatment. All information is confidential.

Severe Moderate Slight Major Complaint(s), in order of importance to you:

1. □ □ □

2. □ □ □

3. □ □ □

4. □ □ □

5. □ □ □

The Fertility Cure, LLC. Health History Questionnaire CONFIDENTIAL

www.thefertilitycure.com

Date First Name Last Name Middle Initial

_____ / _____ / _____

Gender Date of Birth Age Eye Color: Height: Weight:

M F _____ / _____ / _____

Street Address City State Zip

Phone (Daytime) – Home Work Mobile Circle One Phone (Nighttime) # – Home Work Mobile Circle One

( ) ( )

Alternate Phone # – Home Work Mobile Circle One Place of Employment Occupation

( )

Name & Phone Numbers of Partner: Name & Phone Numbers of Emergency Contact:

Primary ( ) Alternate ( ) Primary ( ) Alternate ( )

E-Mail:

□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□How did you hear about us? Please circle one and write the name

Current Patient: __________ Doctor: __________Advertisement: __________ Friend: ________Insurance: ___________ Other:____________

Have you received a Diagnosis for your condition(s)? Y / N If so what: Have you had Acupuncture before? Y / N

By Whom: Did you have a positive □ Experience □ Out come

When/how did this condition occur? Give dates if possible. 1)

2) 3)

How do these conditions impair your daily activities? 1)

2) 3)

Treatment(s) you have received for this condition: 1)

2) 3)


SYMPTOMS – NOTE: For each symptom you currently have, rate its severity from 1-5 (5 being the worst).Leave blank if Not Applicable.

LIVER / GALLBLADDER Poor Memory Low Resistance to Colds or FluIrritability / Anger Loss of Hair SneezingDepression / Stress Hearing Problems Mild Fever Comes & goesHeadaches / Migraines Cavities Smokes CigarettesVisual Problems Fear EmphysemaRed / Dry / Itchy Eyes Hot Flash/ Night Sweating BronchitisGall Stones Do you crave: Salty Black / Blood in StoolsDizziness ConstipationBlurred Vision Heart / Small Intestine IBSFeeling of Lump in Throat Heart Palpitations Colitis/ Spastic ColonClenching of Teeth at Night Chest Pain DiarrheaMuscle Cramping /Twitching

Insomnia / Sleep Problems Do you Crave : Pungent

Tension Easily StartledJoints/Neck/ShoulderPain/Tight Restlessness / Agitation

SPLEEN / STOMACH

Poor Circulation Vivid Dreams Heaviness Anywhere in the BodySoft / Brittle Nails

Lack of Joy in LifeFatigue on a Scale of1(low) –10 (high)

Emotional Eater Do you crave: Bitter Hard to get up in the MorningBad Taste Muscles Feel Tired Often

Bad Breath LUNG / LARGE INTESTINEEdema (swelling) □ hands

□ feetDo you Crave: Sour Bloody Cough Easily Bruising & Bleeding

Dry Cough Bad BreathKIDNEY/ URINARY BLADDER Cough with Sputum Nausea/ Vomiting

Urinary Problems Nasal Discharge / Circle Color - Difficulty Digesting Fatty FoodsBladder Infection White Yellow Green Nausea/ VomitingDropped Bladder Post Nasal Drip / Circle Color: Gas / BelchingIncontinence White Yellow Green HemorrhoidsLack of Bladder Control Sinus Infection/ Congestion ConstipationWeakness/ Pain in LowerBack Itchy, Red, or Painful Throat DiarrheaDecrease Bone Density Dry Mouth/ Throat/ Nose Abdominal PainFeel Cold Easily Skin Rashes / Hives Indigestion / HeartburnCold Hands Snoring Over - ThinkingCold Feet Grief / Sadness Tendency to Gain Weight

What treatments helped the most? 1)

2) 3)

MEDICAL CONDITIONSPlease List conditions & surgeries you have had and yeardiagnosed.

ALLERGIESMedications, Seasonal,Environmental, Food.

OCCUPATIONALCONCERNSCheck ( √ ) if your workexposes you to the following:

DIET & EXERCISECheck ( √ ) all that apply.

YearSurgery/ Hospitalization/ Accidents/

Trauma (Physical & Emotional)□ Stress

□ Environmental

□ Heavy Typing

□ Heavy Lifting

□ Others:

□ Regular Exercise

□ Low-Fat

□ Low-Carb

□ Vegetarian

□ Other:

□ Drink Coffee: Cups/Day

Occupation:_____________________

□ Drink Soda oz/Day


Low Sex Drive / Libido Shortness of Breath Brain FoggyExcess Sexual Desire Allergies / Asthma Do you Crave: Sweet

MEDICATIONS – Please list all prescription medications you use. Include those which you may only use occasionally. Rememberinhalers, eye drops, nose sprays, and topical creams. NOTE: If need more space, use page 5.

Prescription Name Purpose How Long Dose How Often Last Dose

PERSONAL MEDICAL & FAMILY HEALTH HISTORYPlease indicate those that are current health problems for yourself and your family members with a “C” under the appropriateperson’s column. “P” should be used to indicate a past problem. Leave blank those that do not apply. If you require morespace, use the space below.

You Father Mother Spouse Brother(s) Sister(s) ChildrenAge

AIDS / HIVAlcoholAnxietyAnorexia / BulimiaArthritisAsthma / Hay Fever / AllergyBack TroubleBursitisCancerConstipationDepressionDiabetesDigestive TroubleHeadachesHeart TroubleHepatitisHigh Blood PressureImmune DisorderInsomniaKidney TroubleLiver TroubleMigraineNeck PainThyroid DisorderTobaccoWeight ProblemOther EmotionalProblems:__________________

Other:______________________

If any of the above family members are deceased, please list their age at death and cause.

_________________________________________________________________________________________________________________________


MUSCULOSKELETAL

□ Muscle Cramps – Where? □ Muscle Pain / Rheumatism – Where? □ Arthritis – Where?

□ Joint Swelling – Where? □ Tendonitis – Where? □ Bursitis – Where?

What Makes this Better? :

Please mark problem areas on diagram:

Location ofPainIs the Pain □ Sharp □ Burning □ Aching

□ Fixed □ Numbness

□ Tingling □ Other:___________________

On a Scale of 1 ( Low) – 10(unbearable):Is the PainBetter With:

□ Rest □ Activity □ Ice

□ Heat □ Other:________________

□ Massage □ □ Chiropractic



□ Tingling □ Other:___________________



□ Heat □ Other:________________




□ Tingling □ Other:___________________



□ Heat □ Other:________________




□ Tingling □ Other:___________________



□ Heat □ Other:________________



Women Only Men Only

Hysterectomy – Ovaries Removed? □ Yes □ No

Could You be Pregnant Now? □ Yes □ No

Number Of: ___ Pregnancies ___ Miscarriages___ Births ___ Abortions

Post-menopausal Bleeding □ Yes □ No

When did your last period start? ________________

Number of days for menstrual cycle? ________________

Number of days bleeding lasts? ________________

Describe Menstrual Flow:

□ Heavy □ Moderate □ Light □ None

Color of Menstrual Flow:

□ Dark □ Bright Red □ Slightly Reddish

Birth Control:

□ None □ IUD □ Birth Control Pills

□ Spermicides □ Barriers

Do You Suffer From:

□ Cramping (Mark as appropriate)

□ Cramping in LowBack

□ In Groin Area

□ Moderate

□ Severe □ Before Period

□ Mild □ Do you feel Ovulation

□ During Period □ After Period

□ Do you us painMedication?

What Kind of Medication?:

□ Clotting (Mark as appropriate)

□ Bright in Color □ Brown / Grainy

□ Stringy □ Dark in Color

□ Size of Clots : Nickel/ Dime / Larger

□ Bleeding Between Periods □ Infertility

□ Pelvic Inflam. Disease □ Ovarian Cysts

□ STD’s □ Hot Flashes

□ Endometriosis □ Breast Cysts

□ Mastitis

□ Yeast Infection / Vaginitis / Other Discharge

□ Premenstrual Syndrome (Mark as appropriate)

□ Fluid Retention □ Cravings

□ Fluctuating Emotions □ Irritability

□ Tenderness in Breasts □ Depression

□ Fatigue □ Loose Stool

□ Tender / Weepy

□ Impotence □ Weak Erection

□ Discharge from Penis □ Prostate Problems

□ Testicular Pain or Lump □ Infertility

□ Premature Ejaculation □ Low Sex Drive

□ STD’s

Men and Women

Supplements

Name Purpose How Long

Notes / Anything Else

Thank you for completing this form. Your timeis greatly appreciated and we value this

opportunity to serve you!


.

1. Fertility treatments (including cancelled cycles):Date Natural, IUI

IVF, OtherMedication

Used# of Mature Eggs /

FolliclesPregnancy

Yes/NoIf Miscarried ,

Indicate at which WeekOther Comments

and Locations

2. Patient Diagnostics / DateElevated

FSHUterineFibroids /Polyps

Endometriosis /Adhesions

PCOS POF LowProgesteroneLevel

PID STD’s Herpes

Others:

3. If the patient has PCOS, are they taking:Glucophage Fortamet How long? Are you taking extra B-Complex Vitamins?

4. Female Health:PID Chlamydia STD’s Herpes Antisperm

AntibodiesOthers

5. Procedures performed cont. / DatesLaparoscopy HSG-Hysterosalpingogram Others:

6. Lab Results/ DatesFSH Level

Day 3HCG Prolactin TSH T3: T4: Free T4: Others

7. Lab Results on File Y / N

8. Supplements and/or Vitamins?Date Prenatal Fish Oil Greens

PlusAntioxidants Royal Jelly/

PropolisAdditional Folic

AcidOthers

The Fertility Cure, LLC. Female Fertility Form CONFIDENTIAL



_____ / _____ / _____

Date of Birth Age Body Type Height: Weight: Complexion: Occupation:_____ / _____ / _____

LMP: Cycle Duration

RE & I Clinic / Fertility Specialist: RMFC / CCRM / FCC / Conceptions / CUOther OBGYN doctor Start Date: Month/ Year

Western Diagnosis


9. Planned ART / Date:IUI w/ Injectables IUI w/ Oral

MedsClomid IVF PGD Other

10. Fertility History / DatesPregnancies Children Miscarriages Abortions Ectopics D&C Abnormal Pap

SmearOthers

11. Other:Age at which menses began? ___________OCP ___________ How long? ___________List name of birth control ______________________________________How long has patient TTC? _______________________Clomid challenge test? _____________________ Date:_____________Day 3______ at Day 10______ at ____________(month/year)

Recurrent yeast infections? _________ How often? __________

Natural Ovulation ………….. Y / NWhich day of your cycle ______ to ______Typically, how many days are there from one period tothe next _____ to _____ days?Today is which day of patient’s cycle? ________Current month treatment plan _____________(Natural, IUI, IVF, Any Tests, etc.)

9. PMS 10. Menstrual History10 DaysBefore

1 WeekBefore

2-3Days

Before

Symptoms(please check each day)

Day1

Day2

Day3

Day4

Day5

Day6-7

BreastTenderness

Do you have Back Pain?

Depression Cramps (Light, Medium,Severe)

Fatigue Color (Light Red / Red /Dark Red / Brown)

Low BackPain

How Heavy is Flow (Light,Normal, Heavy)

Face BreakOut

Is there Clotting?

OtherIs there Spotting?

11. Is partner currently being treated by us? Y / N

12.

13.

14. Do we have copies of labs / sperm analysis Y / N

15. Results for Sperm Analysis:Date Count Morphology Motility Volume

16. Male Reproductive History/ Date:Varicocele Vasectomy Vasectomy Reversal SCSA / DNA Anti- Sperm Antibodies Others

Partner’s Name

Western Diagnosis of the partner:


17. Following Fertility :

Basal Body Temperature Chart Y / N Avoid Ice cold Foods………... Y / NTimed Sex …………………… Y / N Avoid Tampons……………… Y / NStress Reduction ……………… Y / N Femoral Massage …………… Y / N

Diet Principals : □ Yin Visualization…………………. Y / N

□ Yang Meditation …………………... Y / N

□ Blood Yoga …………………………. Y / N

□ Qi Qi Gong………………………. Y / N

Ovulation Deep Breathing……………… Y / NJournaling……………………. Y / N

LH Sticks ……………………… Y / N Foot Soaks…………………… Y / NOPK …………………………… Y / N Feminine Hygiene…………… Y / NRelationship / Sex …………….. Y / N Detox……………………….... Y / N

Type of DetoxFeng Shui…………………….. Y / N

© The Fertility Cure, LLC. 2007

NameDateDate of LMP

CYCLE

PMS CRAMPING MEDICINES TAKEN

DateDate of LMPCycle Length

CYCLE


DateDate of LMPCycle Length

CYCLE


The Fertility Cure, LLC. Cycle At A Glance CONFIDENTIAL


Cycle Length# of days of spotting prior to period# of days of spotting after period

Day 1 □ Spotting □ Heavy □ Moderate □ Scanty □ Brown □ Red □ Purple □ Crimson □ Clots





Day 6-7 □ Spotting □ Heavy □ Moderate □ Scanty □ Brown □ Red □ Purple □ Crimson □ Clots

□ Low Back Pain □ Irritability □ Night Sweats

□ Uterus □ Aspirin □ Aleve □ Other How Many per Day?___________

□ Ovulation Pain □ Tender / Weepy □ Loose Stool □ Groin □ Motrin □ Midol

□ Tender Breasts □ Fatigue □ Low Back □ Tylenol □ Ibuprofen Which day of your Cycle__________

# of days of spotting prior to period# of days of spotting after period











# of days of spotting prior to period# of days of spotting after period












1. Results for Sperm Analysis:Date Count Morphology Motility Volume

2. Do we have a copy of your Semen Analysis? Y / N

3. Other Procedures/ Date:Varicocele Vasectomy Vasectomy Reversal SCSA / ASA Others

4. Do you take any of these Supplements and/or Vitamins?# of Monthson Vitamins

Male Vitamins Mega Man Fish Oil L - Carrnatine L - Arganine Antioxidants EWA Complete List

Other:

5. Couples ART Plans:IUI Clomid IVF PGD TESA Other

6. Has the patient father children Y / N If so, how many _________________

7. Male HealthInfection Chlamydia, Erectile

DysfunctionEjaculationProblems

RetrogradeEjaculation

Prostate

Y / N Y / N Y / N Y / N Y / N

8. Male Health ContinuedAntispermAntibodies

Sperm Chromatid /DNA Integrity

High Cholesterol Diabetes(fasting, glucose)

Others

Y / N Y / N Y / N Y / N

9. Is you Spouse currently being treated by us? Y / N

10.

11.

The Fertility Cure, LLC. Male Fertility Form CONFIDENTIAL



_____ / _____ / _____

Gender Date of Birth Age Body Type Height: Weight: Complexion: Occupation

M F _____ / _____ / _____

Name of your doctor/ Fertility Specialist: RMFC / CCRM / FCC / Conceptions / CUOther OBGYN doctor Start Date: Month/ Year

Western Diagnosis

Spouse’s Name

Western Diagnosis of Spouse

Cycle At A Glance - wholehealthcenters.com · Incontinence White Yellow Green Hemorrhoids Lack of...

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