Fertility Consultation Form

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AcuHealthcare Fertility

Consultation

Please take the time to fill out the information below, to help us understand your circumstance

First Name

Last Name

Email

Date of Birth

Phone

Address

Occupation

Marital Status

How did you hear about AcuHealthcare?

Reason for visit today?

Doctors Name

Doctors No.

If yes, for what?

Any other Current Therapies?

Health History

Accidents/Injuries/Falls/Traumas

Major Illnesses/ Surgery (dates)

Current Medications (Including Vitamins)

Lifestyle

Sleep Pattern

Energy LevelLowOkayAverageGoodAwesomeEnergy Level

Stress LevelNot StressedNot often StressedStressed 3-5 times a weekStressed once a dayVery often StressedStress Level

Systems Analysis

Please tick if applicable

Musular Skeletal

Neck/Shoulder Pain

Joint Pain

Back Pain

Muscle Pain

Arthritis

Circulatory

H/L Blood Pressure

Varicose Veins

Blood Clots

Heart Palpitations

Tired Legs

Respiratory

Frequent Colds

Hay Fever

Sinusitis

Asthma/Wheezing

Cough

Genitourinary

Frequent Urgent Urination

Wake to Urinate

H/L Libido

Pain on Urination

Kidney Stone

Skin & Hair

Eczema/Psoriasis

Dry Skin/Hair

Itching

Acne

Hair Loss

Gastrointestinal

Constipation/Diarrhea

Bloating

Nausea

Hemmorrhoids

IBS

Neuropsychological

Headaches/Migraines

Poor memory

Irritability

Depression

Anxiety

Senses

Glasses or Lenses

Ear Infections

Deafness

Vertigo/ Dizziness

Tinnitus

Reproductive Health

Menstrual History

Age at which Menses began

Date of last Period

Length of Cycle

How many days bleed

Colour of Blood

Light Red

Red

Dark Red

Purple Brown

Black

Black Spot between Periods

Do you experience any of the following?

Painful Periods

Light Periods

Heavy/Clots

PMT

Tender Breasts

On what day of your cycle?

If yes, for how long?

Pregnancy History

How many pregnancies have you had?

How many children do you have?

Ages of Children?

How many miscarriages have you had?

How many time has a D&C been performed?

Gynecological Conditions

Date of last Pap Smear?

Have you ever been diagnosed with;

Uterine fibroids or polyps

Endometrioses

PCOS

Pelvic Adhesions

Fertility

Please give details

Results

Results ie Estrogen, Progesterone, LH

How long have you been trying to conceive?

Has you partner undergone fertility investigations?

Any other comments

Your Signature

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