Wufoo
Fertility Consultation Intake Form
Confidential Intake of Reproductive Health History - Fill out the intake form below in as much detail as you can. Once you submit this form it will be sent to our herbalists. You should receive your consultation back within 5 business days. *Do not hit the refresh button while filling out your form, all of your data will be erased. PLEASE be sure to fill out your entire intake form all in one sitting. Leaving the page open for later, or coming back to it another time may cause you to lose your information and the entire page may not submit correctly.
Name
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First
Last
Consultation Order Number and/or Customer ID Number
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Location
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Email
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Current Age
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Current Weight
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Height
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What is your main goal or expectation from this consultation?
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Are you currently working with a Reproductive Endocrinologist, Acupuncturist, Naturopathic Doctor or Herbalist? If yes please let us know which in the box below.
Please list all supplements and herbs you are currently taking - include how long you have been taking each product, the brand name of the product, the exact dose, as well as the reason you are taking the product.
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Please list all medications you are taking, how long you have been taking each medication and why you are taking them. Please be very specific.
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Do you have allergies? If yes list them below
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Have you ever been pregnant?
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Yes
No
How long have you been trying to get pregnant?
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Have you had an IUI or IVF?
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Yes
No
Do you ovulate monthly?
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Yes
No
Not sure
If so how do you know?
Do you have pain when you ovulate?
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Yes
No
Are you tracking your temperature with a thermometer and fertility chart?
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Yes
No
Do you have cervical mucus?
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Yes
No
Have you ever been on the birth control pill, when and how long?
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How many days is your menstrual cycle? (typical is 28 days)
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How many days do you menstruate?
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Do you experience any of these menstrual issues (check those that apply):
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Clots during menstruation
Heavy bleeding during menstruation
Cramps
Light bleeding during menstruation
Spotting midcycle
Lack of menstruation
Long cycles (longer than 7 days)
PMS
None
If you checked any of the menstrual issues above please let us know for how long and specifically what issues you are currently experiencing.
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What color is your menstruation?
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Light pink
Dark brown or dark purple
Bright red
Have you been diagnosed with any pelvic abnormalities?
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Yes
No
Have you had any of the following (check all that apply):
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Endometriosis
Uterine Fibroids
Ovarian Cysts
Polyps
HPV
STD's
Yeast Infections
PCOS
Fibrocystic Breast Disease
Abnormal Pap
Unexplained Infertility
Recurrent Miscarriages
Ectopic Pregnancy
Tubal Ligation Removal
Lack of Cervical Mucous
Blocked Fallopian Tubes
Premature Ovarian Failure
Hypothyroidism
Secondary Infertility
None
Are you currently experiencing any of the issues mentioned in the previous question? For how long?
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Has anyone in your family had troubles conceiving?
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Yes
No
Do you drink alcohol?
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Yes
no
Do you smoke cigarettes?
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Yes
No
Do you drink caffeine?
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Yes
No
Do you take recreational drugs?
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Yes
No
If yes, what kind and how often?
Diet & Exercise
What do you typically eat and drink for Breakfast? (Be specific)
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What do you typically eat and drink for Lunch? (Be specific)
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What do you typically eat and drink for Dinner? (Be specific)
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What do you typically eat and/or drink for Snacks? (Be specific)
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What are your top 3 favorite foods?
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Check all that best describe your digestive function.
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Gas, discomfort after eating
More than a day between bowel movements
More than 3 bowel movements in a day
Tendency towards dry, hard stools
Tendency towards loose stools
None
What is your exercise regime?
What is your stress level?
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Very high
High
Moderate
Light
None
What is your favorite way to relax or reduce stress?
*
Please fill in the following
Has your male partner had a sperm test or considered male factor infertility as part of your difficulties in achieving pregnancy or carrying to term?
No
Yes
Have you had any DNA testing done?
*
Yes
No
So far what have you tried to help you get pregnant?
*
Maximum of
400
characters.
Currently Used:
0
characters.
What are your top 3 fertility questions? This helps us to make sure we address all of your concerns.
Fertility Question #1
*
Maximum of
400
characters.
Currently Used:
0
characters.
Fertility Question #2
Maximum of
400
characters.
Currently Used:
0
characters.
Fertility Question #3
Maximum of
400
characters.
Currently Used:
0
characters.
Is there any additional information pertaining to your present fertility health within the last year or goals that you would like to share?
Maximum of
400
characters.
Currently Used:
0
characters.
Important
*
Add our email - consultations@naturalfertilityshop.com - to your contacts to make sure you receive our emails.
This is to acknowledge that I have been informed and understand that:
1. I understand that the information shared during the consultation is for educational purposes only and is not intended to replace or suggest that I refrain from seeking or following the advice of another licensed health care provider.
2. I also understand that there are no guarantees with natural therapies and there are no promises or claims that I will become pregnant.
*
I agree
I do not agree
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