Balancing Point Center for Wellness WOMEN’S FERTILITY QUESTIONNAIRE Name: ___________________________________________ Date: _______________________ 1.Basic Information
a. Address: ____________________________________________________________________________________________
2. Menstrual History 3. Gynecologic History
a. At what age did you begin your menses? ________
a. Date of Last Pap Smear : ________________
c. When was your last menstrual cycle? ________________
Do you have any problems with your cycle?
o Had/have chronic vaginal discharge? No Yes
o Had/have sores on your genitalia? No Yes
j. Premenstrual Symptoms (Mark al that Apply)
o Luteinized unruptured fol icle syndrome? No Yes
Have you ever been diagnosed with (Mark al that apply):
Endometriosis Yeast Infection Lupus Diabetes
High Blood Pressure High Fevers Asthma Arthritis
4. Family History
a. Do you have family history of (If marked yes, please explain):
Cancer Diabetes Heart Disease High Blood Pressure Stroke Mental Il ness Kidney Bladder Disease Thyroid Disease Arthritis Al ergies
5. Fertility History a. Have you ever been pregnant? No
Yes; If yes, mark al that apply, and write how many timed
b. How long have you been trying to conceive? <6 Months
6-12 Months 12-18 Months 18-24 Months 2-3 Years
c. Have you had fertility treatments? No Yes (If Yes, please mark which, list dates)
ZIFT Microimplantation Other: ___________________________
i. When and Where? _____________________________________________________________________________________
d. What other treatments have you tried? Acupuncture Herbs
Other (Explain): __________________________________________________________________________
When and how long? _______________________________________________________________________________
f. Do you take any other medications? Antihistamines Decongestants Aspirin Advil/Aleve Antibiotics Antidepressants Insulin Others: ___________________________________________________________________________________________
g. Have you been charting your fertility with basal body temperature? No
h. Have long have you been trying to achieve pregnancy with your current partner? ___________________ i. Have you ever tried to conceive with a different partner?
ii. Has your male partner gotten someone else pregnant?
i. Are you seeing a reproductive specialist? No
j. Have you been diagnosed with infertility? No
6. Physical History (Please mark all that apply):
Is your midcycle fertile cervical mucus scanty or missing?
Do you have dark circles around or under your eyes?
Would you describe yourself as afraid a lot?
Kidney Yang Xu
Do you have lower back pain premenstrual y?
Are your feet cold, especial y at night?
Are you typical y colder than those around you?
Do you wake up at night or early in the morning because you have to urinate?
Do you urinate frequently, and is the urine diluted and/or profuse?
Do you have early morning loose, urgent stools?
Does your menstrual blood tend to be dul in color?
Do you feel cramps during your period that respond to a heating pad?
Spleen Qi Xu
Do you have loose stools, abdominal pain, or digestive problems?
Are you prone to feeling heavy or sluggish?
Are you prone to feeling heaviness or grogginess in the head?
Are you lacking strength in your arms and legs?
Have you been diagnosed with low blood pressure?
Do you sweat a lot without exerting yourself?
Do you feel dizzy or light-headed, or have visual changes when you stand up fast? �
Is your menstruation thin, watery, profuse, or pinkish in color?
Are you more tired around ovulation or menstruation?
Do you ever spot a few days or more before your period comes?
Have you ever been diagnosed with uterine prolapse?
Are you often sick, or do you have al ergies?
Have you been diagnosed with hypothyroid or anemia?
Are your fingernails or toenails brittle?
Are you losing hair on your head (not in patches, but al over)?
Do you have diminished nighttime vision?
Do you get dizzy or light-headed around your period?
Is your menstrual flow ever brown or black in color?
Do you feel midcycle pain around your ovaries?
Do you have painful, unmovable breast lumps?
Do you experience periodic numbness of your hands and feet (especial y at night)? �
Do you have red hemangiomas (cherry-red spots) on your skin?
Does your complexion appear dark and “sooty”?
Does your menstrual blood contain clots?
Have you been diagnosed with endometriosis or uterine fibroids?
Is your lower abdomen tender with pressure?
Can you feel any abnormal lumps in your lower abdomen?
Do you have piercing or stabbing menstrual cramps?
Have you been diagnosed with vascular abnormality or blood clotting disorder?
Liver Qi Yu
Do you feel bloated or irritable around ovulation?
Does it feel as if your ovulation lasts longer than it should?
Are your breasts sensitive/sore at ovulation?
Do you experience nipple pain or discharge from your nipples?
Do you have a lot of premenstrual breast distention or pain?
Have you been diagnosed with elevated prolactin levels?
Do you have difficulty fal ing asleep at night?
Do you experience heartburn or wake up with a bitter taste in your mouth?
Do you feel your menstrual cramps in the external genital area?
Is the menstrual blood thick and dark, or purplish in color?
Do you wake up early in the morning and have trouble getting back to sleep?
Do you have heart palpitations, especial y when anxious?
Do you seem low in spirit or lacking vitality?
Are you prone to agitation or extreme restlessness?
Do you sweat excessively, especial y on your chest?
Are you thirsty for cold drinks most of the time?
Do you often feel warmer than those around you?
Do you wake up sweating or have hot flashes?
Do you break out with red acne (especial y premenstrual y)?
Do you have vaginal irritation or rashes?
Do you feel tired and sluggish after a meal?
Do you have urgent, bright, or foul-smel ing stool?
Does your menstrual blood contain stringy tissue or mucus?
Are you prone to yeast infections and vaginal itching?
Do your joints ache, especial y with movement?
Do you have foul-smel ing, yel ow, or greenish vaginal discharge?
Are you prone to vaginal and/or rectal itching premenstrual y?
ACUPUNCTURE INFORMATION & INFORMED CONSENT Needles Only sterile, disposable needles are used. What To Expect On Your First Visit
•Al ow yourself 1hour for your first treatment and 30-45 minutes for follow-up visits. •Always eat before you come for the treatment. You should not have acupuncture when you are
hungry. •Once escorted into a treatment room, the Doctor wil begin your evaluation by asking you many
questions. •General y speaking, the Doctor wil not discuss your diagnosis in oriental medical terms.
•Upon conclusion of your first visit, the Doctor wil make a treatment recommendation. This may include a certain number of treatments within a certain amount of time. Please take these suggestions
seriously as they are based on years of experience as wel as your individual circumstances, and are important to your health and wel -being.
•Please utilize this time to ask any questions that you may have. What To Expect AFTER Your First Visit
•After the treatment, the most common feeling is being relaxed but some people feel energized. Take a
few minutes to rest and drink some water. •Note how you feel: both physical y, mental y, and emotional y until the next treatment. Please inform
your Doctor of any changes at your next visit so your treatment can be modified if necessary. •On rare occasions one's original symptoms may briefly get worse after the first treatment. A flare-up
typical y occurs later on the day of your treatment for a few hours and then improvement and relief follow. In the long run, acupuncture does not make symptoms worse.
•After the treatment, please do not exercise vigorously for the rest of the day. A mild walk is fine. •Please avoid exposure to extreme hot or cold temperature after the treatment.
•If you have any additional questions or concerns after your treatment, please do not hesitate to telephone or email us. X_________________________________________________ _____________________ Signature
PHOTOSENSITIZING LIST Certain food/drugs do not mix with ultraviolet light. Anyone taking any medication should consult with a Physican PRIOR to tanning. Antihistamines Amoxapine Coal Tar derivatives Fluorouracil Anticonvulsants Anesthetics (Procaine Cold Salts 5-Fluorouracil (5-Fu) Antifungals Combipres Fluoxetine Anti-inflammotory Angelica Com
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