|
What are your main health concerns?
|
|
|
Health History
|
|
|
Please list any other medical conditions you have.
|
Are you under the care of a physician for this or other conditions?
|
|
Please list any surgeries or major health incidents (accidents, surgeries etc.) in your life:
|
|
|
Medication
|
|
|
Please list any prescription medications you take
|
Please list any prescription or over-the-counter medications you take (includies allergy medicines, ibuprofen, acetaminophen):
|
|
Supplements
|
|
|
Please list any supplements you take along with the brand if you know it.
|
|
|
General Health
|
|
|
Do you eat 3 meals per day?
|
Do you snack in between meals?
|
|
Do you have a bowel movement everyday?
|
Do you have any digestive discomfort?
|
|
If 1 is low and 10 is boundless, how would you rate your energy levels on a daily basis?
/
|
If 1 is low and 10 extremely high, how would you rate your general stress level?
/
|
|
How many hours of sleep do you get on average per night?
|
Do you wake feeling rested?
|
|
Do you get headaches?
|
Do you have any musculoskeletal pain?
|
|
Do you have any allergies? (seasonal or food/food sensitivities)?
|
When is the last time you took antibiotics?
|
|
Cycle Information
|
|
|
Age of first period
|
Date of last period
|
|
Number of days between periods (i.e. between the first day of your period until the next period)
|
Number of days of flow
|
|
Color of flow
|
New Short Text Field
|
|
Amount of flow?
|
Pain and cramping, 1/10, 1 being mild, 10 being severe
|
|
Number of children
|
Number of pregnancies
|
|
Dietary Habits-Please indicate the use and frequency of the following:
|
|
|
Coffee
|
Soda
|
|
Water
|
Alcohol:
|
|
Recreational drugs
|
Tobacco
|
|
Please indicate if the following pertain to you:
• • •
|
How would you describe your libido?
|
|
Fertility History
|
|
|
How long have you been trying to conceive?
|
Have you seen any physicians for this issue? Whom?
|
|
Has a physician diagnosed a difficulty with fertility due to:
• • •
|
Other Fertility Difficulties
|
|
Partner information (if conceiving with a partner)
|
|
|
Has your partner had a semen analysis? Please include the approximate date if you recall
|
Were any problems detected?
|
|
If so, has your partner sought treatment or any lifestyle changes for the issue?
|
Has your partner ever gotten someone pregnant?
|
|
What medical conditions does your partner have (if any)?
|
|
