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FERTILITY PATIENT
INTAKE FORM – NATUROPATHY

133 Catherine Street, Leichhardt NSW 2040
02 9555 8806

Confidentiality assured

Female General Details

First Name

Email Address

Last Name

Date of Birth

Do you have a GP and/or specialist practitioner?

Ocupation

Please list the name and dosage of your current medications/ supplements:

Male General Details

First Name

Email Address

Last Name

Date of Birth

Do you have a GP and/or specialist practitioner?

Ocupation

Please list the name and dosage of your current medications/ supplements:

Female & Male

Address

Reproductive Health

How long have you been trying to conceive?

Have either of you previously conceived?

If yes, what were the results of the previous conception?

Were these conceptions a result of natural conception? Or assisted reproductive techniques?

Were these conceptions with your current partner?

Assisted Reproductive History (ART)
Have you undergone any of the following procedures?

Clomiphene/ Clomid?

IVF

IUI

ICSI

PICSI

Further Details

Female Reproductive History

Have you charted your basal body temperature?

Have you used ovulation predictor kits?

Have these methods been successful for you?

Have you charted your cervical mucus?

If yes, which days do you ovulate?

Have you had uterine/pelvic surgery?

How would you rate your libido?

Have you ever been diagnosed with any of the following?

Endometriosis/ Adenomyosis

Poly Cystic Ovarian Syndrome (PCOS)

Fibroids

Candida (thrush)

Genito-urinary infections (cystitis)

Sexually transmitted disease

Genital herpes/ blisters/ warts

Pelvic inflammatory disease

Ovarian cysts

Pain or bleeding during or after intercourse

Please elaborate on your experience here

Have you undergone any of the following investigations?

Ultrasound

Hycosy

Hysterosalpinogogram

Hysteroscopy

Laparotomy

Laparoscopy

Colposcopy

Laser Treatment

Hormone levels

Pain or bleeding during or after intercourse

Please elaborate on your experience here

Menstrual Cycle Details

How old were you when you had your first mensrual cycle?

How many days do you bleed for?

Is the bleed...

Do you experience mid-cycle pain?

How often do you have a period? Please include your average length of your cycle.

Is the bleed...

Do you experience mid-cycle spotting?

Are you currently undertaking hormonal treatment?

Do you need/use painkillers during your period?

Please list the number of days, severity and timing if you suffer from any of the following:

Abdominal cramping

Nausea/vomiting

Constipation/diarrhea

Sore breasts

PMT

Spotting

Contraception History

Are you currently using contraception? Which method?

Did you suffer any side effects?

Back ache

Headache

Skin problems

Fluid rentention

Fatigue

Recent changes to your cycle?

Have you used a contraceptive pill in the past? Which one?

Please list any other methods of contraception you have used?

Digestive Health - please select what applies to you

Female to complete

Bloating

Flatulence

Reflux/Heartburn

Indigestion

Nausea

Abdominal Pain

Diarrhea

Food intolerances

Do you take any medications like antacids, laxatives, antibotics or aspirin on a regular basis?

Have you had any medical investigations like colonoscopy/endoscopy?

Male to complete

Bloating

Flatulence

Reflux/Heartburn

Indigestion

Nausea

Abdominal Pain

Diarrhea

Food intolerances

Do you take any medications like antacids, laxatives, antibotics or aspirin on a regular basis?

Have you had any medical investigations like colonoscopy/endoscopy?

Male Reproductive Health
Have you had any of the following medical investigations?

Semen analysis

Blood tests for thyroid function

Blood tests for hormone levels

Ultrasound

Have you undergone surgery to your reproductive organs?

Vasectomy

Undecended Testes

Testicular disease/disorders

Do you use saunas/ spas regularly, wear wetsuits, or bike ride regularly?

Any history of mumps since puberty?

Do you regularly use cold and flu tablets, anti-inflammatories, or allergy medication?

Have you received any other treatment for reproductive problem?

Female to answer

Do you smoke cigarettes/ have you in the past? How many per day?

Do you consume caffeinated beverages/foods such as coffee/tea/energy drinks/chocolate?

Do you consume alcohol?

Do you use recreational drugs?

Do you exercise? What type?

Please rate your stress levels

Please rate your energy levels

Do you experience problems with sleep quality?

Variocele

Hypospadias

Prostate disease

Any history of sexually transmitted disease including herpes?

Have you ever used any treatments for hair loss?

Any history of hormonal or steroid use?

How would you rate your libido?

Male to answer

Do you smoke cigarettes/ have you in the past? How many per day?

Do you consume caffeinated beverages/foods such as coffee/tea/energy drinks/chocolate?

Do you consume alcohol?

Do you use recreational drugs?

Do you exercise? What type?

Please rate your stress levels

Please rate your energy levels

Do you experience problems with sleep quality?

Medical History - self and family

Allergies

Autoimmune Disease

Cardiovascular Disease

Ezcema or Psoriasis

Fibroids

Hospitalisations/operations

Sexually Transmitted Disease

Arthritis

Bowel Disorder

Depression

Epilepsy

Gastroenteritis/ Gardia, etc

Hysterectomy

Thyroid Disease

Asthma

Cancer

Diabetes

Endometriosis

Hepatitis

Osteoporosis

Other

Female Diet Diary

BREAKFAST

MORNING SNACK

LUNCH

AFTERNOON SNACK

DINNER

OTHER SNACKS

BREAKFAST

MORNING SNACK

LUNCH

AFTERNOON SNACK

DINNER

OTHER SNACKS

BREAKFAST

MORNING SNACK

LUNCH

AFTERNOON SNACK

DINNER

OTHER SNACKS

WATER INTAKE PER DAY

CAFFEINE INTAKE PER DAY

ALCOHOL INTAKE PER DAY

Male Diet Diary

BREAKFAST

MORNING SNACK

LUNCH

AFTERNOON SNACK

DINNER

OTHER SNACKS

BREAKFAST

MORNING SNACK

BREAKFAST

MORNING SNACK

LUNCH

AFTERNOON SNACK

DINNER

OTHER SNACKS

LUNCH

AFTERNOON SNACK

DINNER

OTHER SNACKS

WATER INTAKE PER DAY

CAFFEINE INTAKE PER DAY

ALCOHOL INTAKE PER DAY

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Darling Health acknowledges the prior ownership of the land the clinic resides on; the Gadigal and Wangal peoples who were the first inhabitants of the nation and the traditional custodians of this land. We pay respect to their ancestors and elders, past, present and emerging, and value their continuing cultural connection to lands, living culture and integral contribution to the vivid and inclusive future of Australia, that we refer to as home.

PRIVACY POLICY | CODE OF CONDUCT

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FERTILITY PATIENT INTAKE FORM – NATUROPATHY

133 Catherine Street, Leichhardt NSW 2040 02 9555 8806

Female General Details

Male General Details

Female & Male

Reproductive Health

Assisted Reproductive History (ART) Have you undergone any of the following procedures?

Female Reproductive History

Menstrual Cycle Details

Please list the number of days, severity and timing if you suffer from any of the following:

Contraception History

Digestive Health - please select what applies to you

Male Reproductive Health Have you had any of the following medical investigations?

Have you undergone surgery to your reproductive organs?

Female to answer

Male to answer

Medical History - self and family

Female Diet Diary

Male Diet Diary

FERTILITY PATIENT
INTAKE FORM – NATUROPATHY

133 Catherine Street, Leichhardt NSW 2040
02 9555 8806

Assisted Reproductive History (ART)
Have you undergone any of the following procedures?

Male Reproductive Health
Have you had any of the following medical investigations?