Female Fertility Intake Form

This form does need to be filled out before your first appointment regardless of whether or not you are an existing patient.

PLEASE NOTE: If we were to go through these questions with you in person, it would take around 30 minutes. After that, we go through further tests (such as pulse, face, palm, ear, tongue diagnosis or thermal scan) followed by a discussion of the findings and recommended treatment plan.

By filling this form, you save around 30 minutes of our time which we would otherwise need to charge you for, resulting in significant savings to you. That is why we created this detailed form; all the questions on this form are questions we would otherwise ask in the initial exam. Now you can answer all these online without any cost.  After that your in person exam will just take 30 minutes and cost only $40.

If you have any trouble with the form, please call reception on 07 846 7956 or reply to this email for assistance. Thank you for your patience.

1. Mobile Phone Number: (this is what we will use to identify this form as yours, so please make sure you write the same number that you give us over the phone.)

1.1 Initials of first and last name.

2. Occupation

3. Do you work for an ACC accredited employer? (if "Yes" go to "4", if "No" go to "5")

4. What is your employer’s name?

5. How did you hear about us?

6. Name of person who referred you if your answer above is "Word of Mouth" or "GP/specialist referral" or "Other"

7. Main Complaint

8. What is the main complaint you are seeking help for at Centre of Balance?

9. When did it begin?

10. Has this problem been medically diagnosed?

11. If yes, what was the diagnosis?

12. What have you done to try to help with this?

13. Have you received any treatments for this condition previously?

14. Home Environment

15. How old is your home?

16. How many years have you lived there?

17. Have you done any recent renovations to your home? If YES, please describe (e.g. painting, new carpets etc):

18. Do you have any household pets? If YES, what type of pet:

19. Do you live near any of the following?

20. Lifestyle Habits

21. What kind of exercise do you do, if any, and how often?

22. Please indicate how many cups of each type of drink you consume per day based on an 8-12 oz cup:

23. Soda/Fizzy Drink

24. Alcohol

25. Coffee

26. Water

27. Are you a smoker? If yes, how often?

28. Are you regularly exposed to second-hand smoke?

29. Do you use (or have you previously used) any recreational drug? If yes, please list which kinds and how often:

30. Medications

31. Are you allergic to any medications that you know of?

32. If you are allergic to any medications, please list the name of the medication and your reaction:

33. Are you currently taking any medications? If yes, please list the medication or supplement you are taking along with the dosage and frequency:

34. Medical Conditions

35. Do you suffer from or have a history of any of the following conditions? (please select "none of the above" if none apply)

36. If "Other" please describe (you can also elaborate on any conditions you may have listed above):

37. Please indicate if you have experienced any of the following symptoms in the last 6 months:

38. Kidney Yin Deficiency (please select "none of the above" if none apply)

39.  Kidney Yang Deficiency (please select "none of the above" if none apply)

40. Spleen Qi Deficiency (please select "none of the above" if none apply)

41. Liver Qi Stagnation (please select "none of the above" if none apply)

42. Blood Deficiency (please select "none of the above" if none apply)

43. Blood Stasis (please select "none of the above" if none apply)

44. Heart Deficiency (please select "none of the above" if none apply)

45. Excess Heat (please select "none of the above" if none apply)

46. Dampness (please select "none of the above" if none apply)

47. Damp Heat (please select "none of the above" if none apply)

48. Cold Uterus (please select "none of the above" if none apply)

49. Family Medical History

50. Is there a history of any of the following conditions in your family?

51. If your family has a history of any of the conditions in the previous questions or you would like to elaborate on a history of any other illness in your family please explain in the space provided (i.e. mother's / father's side, etc.)

52. Gynecologic History 

53. When was the first date of your last period?

54. Are your periods regular? (the number of days between each time you get your period mostly stays the same)

55. Age of first menstrual period:

56. Number of days between periods:

57. Number of days bleeding during period:

58. Amount of bleeding

59. Do you get blood clots during your period?

60. Have you ever needed medication to bring on your period?

61. Do you ever get pain with menstruation?

62. Degree of pain felt with menstruation:

63. Is the pain relieved by over the counter medications such as paracetamol?

64. Does the pain start with the onset of bleeding?

65. Does the pain begin a few days prior to the onset of bleeding?

66. Does the pain persist for more than 48 hours?

67. Do you experience spotting mid-cycle?

68. Do you experience pain with sexual intercourse?

69. Is the pain mostly on the exterior?

70. Is the pain mostly internal (deep penetration)?

71. Do you experience painful ovulation?

72. Do you experience vaginal discharge?

73. Is the discharge associated with itching or burning?

74. Is the discharge associated with an unusual odour?

75. Do you have a Gynecologist?

76. When was your last cervical smear?

77. What was the result of your last cervical smear?

78. What follow-up was needed?

79. Have you ever had a Mammogram?

80. Have you ever had any of the following sexually transmitted infections or diseases? (please select "none of the above" is none apply to you)

81. If "other" please explain:

82. When did you have this infection/disease?

83.  Was it treated?

84. Have you ever had Pelvic Inflammatory Disease (PID)?

85. If yes, when? Were you hospitalised?

86. Do you experience milk or discharge from your breasts?

87. Have you ever had an IUD (Intrauterine device)?

88. Have you ever used the Oral Contraceptive Pill?

89. If yes, for how long?

90. When did you last use it?

91. Surgical History

92. Do you have any history of surgery? If yes, please list the procedures, dates, reasons for surgery and the outcomes below:

93. Obstetric History

94. Have you ever been pregnant before? (If no, please skip to question 108)

95. If you have been pregnant before, please list the estimate dates of your pregnancies or how old you were at the time:

96. Was the pregnancy with your current or prior partner? (Please answer for each of your pregnancies if you have had multiple)

97. How many pregnancies resulted in a live birth?

98. Did you have any pregnancies that ended in miscarriage, abortion or an ectopic pregnancy?

99. How many weeks did the pregnancy last? (Please answer for each of your pregnancies if you have had multiple)

100. Was there a fetal heartbeat? (Please answer for each of your pregnancies if you have had multiple)

101. Did you undergo a D&C (Dilation and curettage) procedure? (Please answer for each of your pregnancies if you have had multiple)

102. What was the mode of delivery? (Please answer for each of your pregnancies if you have had multiple)

103. What was the sex of the baby? (Please answer for each of your pregnancies if you have had multiple)

104. Were there any complications? (Please answer for each of your pregnancies if you have had multiple)

105. Are you currently pregnant?

106. How long have you been trying to have a baby for?

107. Have you ever been diagnosed with uterine fibroids or polyps?

108. Have you ever been diagnosed with endometriosis?

109. Have you ever been diagnosed with Pelvic Adhesions?

110. Have you recently had an ultrasound?

111. If yes, when?

112. Fertility - IVF Treatments 

113. How many stimulated cycles have you had? (please skip to question 128 if you have not undergone any IVF treatment)

114. What was the start date of your cycle? (Please list the start date for each cycle if you have had more than one)

115. How many eggs were collected? (Please list for each cycle if you have had more than one)

116. How many eggs were transferred? (Please list for each cycle if you have had more than one)

117. How many eggs were frozen? (Please list for each cycle if you have had more than one)

118. What was your FSH level? (Please list for each cycle if you have had more than one)

119. Did the cycle result in a positive pregnancy test? (Please list for each cycle if you have had more than one)

120. How many frozen transfers have you had? (If you have not had any frozen transfers please skip to question 128)

121. What was the date of your frozen transfer? (Please list for each transfer if you have had more than one)

122. Did you take progesterone for the transfer? (Please list for each transfer if you have had more than one)

123. Did any of your transfers result in a positive pregnancy test? (Please list for each transfer if you have had more than one)

124. If you have had any cancelled IVF cycles please detail below:

125. Is there anything else you would like to add that you feel is important and has not been covered?