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Fertility Intake Louisville Acupuncture Clinic

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Fertility Intake Louisville Acupuncture Clinic Fertility Intake Louisville Acupuncture Clinic Last Name: First Name: DOB: Number of Name of your Menstrual Cycle Pregnancies Age menstruation began: _______ Cesarean Births Ob/Gyn: __________________________________________ How long have you been trying to Vaginal Births get pregnant? ________________ Abortions Reproductive Endocrinologist: ________________________ (please circle one) My periods are: Miscarriages a) Like clockwork Ectopic(s) Midwife: _________________________________________ Failed IUI’s b) Somewhat regular Failed IVF’s c) Erratic Number of days in a typical Previous Gynecological Surgeries - Check any surgical procedure that you have had menstrual cycle: ______________ Dilation & Curettage (D&C) Laparoscopy (uterine fibroids) If your cycle is erratic: Falloposcopy Mymectomy Shortest # of days in cycle: ______ (HSG) Hysterosalpingogram Neosalpingostomy Hysteroscopy Tuboplasty Longest # of days in cycle: ______ Laparoscopy (endometriosis) Other(s): Menstrual bleeding tends to be: Laparoscopy (ovarian cysts) ________________________________________ a) Light b) Normal c) Heavy Previous Diagnostic Assessments - Check any diagnosis received by your OB/GYN or Fertility Doctor On what cycle day do you typically Advanced Maternal Age Luteal Phase Defect ovulate? _____________________ Amenorrhea Menorrhagia During ovulation, is your cervical Anovulation Ovarian Cyst (single) mucus clear, stretchy and abundant? Anti-sperm Antibodies Ovarian Cyst (multiple) Autoimmune Oopharitis Ovarian Hyperstimulation Syndrome (OHSS) Yes No Cervical Stenosis Pelvic Inflammatory Disease (PID) If not all three of these, describe: Clotting with Period _________ Phospholipid Antibodies ____________________________ Delayed Cycles ____ - ____ Days Polycystic Ovarian Syndrome (PCOS) Menstrual Pain (mild) Premature Menopause Is there clotting with your period? Menstrual Pain (moderate) Premature Ovarian Failure (POF) Yes No Menstrual Pain (severe) Resistant Ovarian Syndrome ------------------------------------------------------------------------------------------------ Elevated FSH ______________ Short Cycles ____ - ____ Days Do you have spotting before or Endometriosis (mild, moderate, severe) Spotting between periods ____ - ____ Days between periods? Yes No ------------------------------------------------------------------------------------------------ Erratic Cycles ____ - ____ Days Unexplained Infertility Fallopian Tube Blockage Uterine Fibroids Do you regularly experience PMS? Habitual Miscarriage Uterine Septum Yes No ------------------------------------------------------------------------------------------------ Hostile Cervical Mucus Other(s): Hyperprolactinemia ________________________________________ (Circle which PMS symptoms you get) Breast tenderness - Diarrhea - Acne List the Fertility Drugs you have taken: __________________________________________________ Bloating - Constipation - Back Pain ___________________________________________________________________________________________________________________________ Food Cravings - Dizziness - Fatigue Medications you use currently: _________________________________________________________ Headache or Migraine - Mood Swings Have you been tested for chlamydia? Yes No - Results: Positive Negative Pain and Cramps - Irritability Has your husband/partner had a semen analysis? _________ Results: _______________________________________ How would you describe your current level of hopefulness towards attaining your fertility goals? (1 being the t feeling of hope, and 10 being the most hopeful) 1 2 3 4 5 6 7 8 9 10 lowes 7410 New LeGrange Rd. #207, Louisville, KY 40222 Email: [email protected] 502.882.0545 www.louisvilleacupunctureclinic.com.
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