Seven Directions Acupuncture
Reproductive Health Initial Intake: Eggs/ Womb
First Name
Last Name
Date of Birth
*What are your goals for our visit?
General health
*My temperature Runs (check all that apply)
I typically feel hotter than most others
I typically feel cold
I have freezing hands and feet
I have a cold low back
My low back is colder during my menstrual period
I am hotter during my menstrual period
I am quick to fluctuate b/w hot and cold
I have night sweats
I have hot flashes
If you indicated night sweats or hot flashes, please indicate frequency:
*How is your sleep?
*Rate stress on a scale of 0-10- 10 being too much to bear:
*Typical emotions
Anger, irritability, or frustration
Fear or Dread
Worry, rumination, overthinking
Too much joy, mania
Grief, sadness
Depression
Anxiety
Panic attacks
Dissociated from body
PTSD
Digestion, check all that apply
Abdominal distension hard, like a drum
Bloating (water retention)
Gas, indigestion, belching
Nausea, even mild
Loose stools typical
Constipation typical
Abdominal pain with toileting
Urgency to pass bowel movement
Incomplete evacuation
Urinary symptoms
Frequent pale urination
Sense of urgency without much output
Heat or pain with urination
Difficulty emptying bladder completely
Blood in urine
*Typical breakfast, lunch, dinner, snacks?
*Caffeine, alcohol, cannabis or related synthetic products, vaping, tobacco, illicit drug use and frequency:
*Headaches, dizziness, faintness or lightheadedness?:
-list which one and frequency of episodes
*How is your Night vision:
Really bad!!
About the same as day
I’m confused by the question
*List any surgeries:
*Are you currently trying to conceive?
If yes, complete TTC history section. If no, skip to menstrual cycle section.
TTC History
How long have you been trying?
< 6 months
6mos - 1 year
6mos - 1 year inconsistently- ie, skipped several months, or not tracking ovulation
Appx 1 year fairly consistently
Appx 1 year inconsistently- ie, skipped several months, or not tracking ovulation
Appx 2 years fairly consistently
Appx 2 years inconsistently- ie, skipped several months, or not tracking ovulation
Appx 3 years fairly consistently
Appx 3 years ie, skipped several months, or not tracking ovulation
More than 3 years
Do you have a period monthly?
Yes No I'm not sure
Do you ovulate?
Yes No I'm not sure
Menstrual Cycle
Age of first period
Date of last period
Date of period before last
Diagnosed or suspected Endometriosis?
Diagnosed or suspected PCOS?
Cycle regular (arriving same number of days per cycle +/- 2 days- eg, 28-30 days)?
Cycle range- how frequently do you get your period outside of IVF/IUI medicated cycles over the most recent 6 month range? (Eg 28-30 days, 35-60 days)
How many days do you typically bleed during your period? (enough blood to need a pad rather than a pantyliner)
0 1 2 3 4 5 6 7 7+
How many days do you typically spot in a cycle? (Pantyliner or nothing needed).
0 1 2 3 4 5 6 7 7+
More info?:
Rust brown Light brown
What color or colors is your period? Fresh red = red like a cut bleeds. You can list when, for example- Day 1 rust brown, day 2 - 4 fresh red.
Do you have cramps?
If yes, when do they occur? check all that apply:
Mid-cycle, around ovulation
1-2 days before period onset
3-4 days before period onset
4-5 days before period onset
5-6 days before period onset
6+ days before period onset
Day 1 of bleeding
Day2 of bleeding
Day 3 of bleeding
Day 4 of bleeding
Day 5 of bleeding
More than 5 days of bleeding
After my period ends
Most days of the month
If yes, how severe are your cramps? Check all that apply.
Mild
Moderate
Severe
If yes, where are they located? Check all that apply.
Lower abdomen
Low back
Thighs
Glutes
Back of legs
Calves
What words would you use to describe your cramps? Check all that apply.
Dull
Achy
Sharp
Stabbing
Throbbing
Pulsating
Spasming
Persistent
Come and go
Pain relieved by heat
Pain worse by heat
Pain relieved by cold
Pain relieved by pressure
Do you have clots? If so, check all that apply
Presence of caper sized clots
Presence of dime sized clots
Presence of nickel sized clots
Presence of quarter sized clots
Presence of greater than quarter sized clots
Clots look like tissue and twigs
Clots look like globs- sticky- would stick between fingers
0-1 clots per menstrual cycle
2-3 clots per menstrual cycle
4-5 clots per menstrual cycle
Greater than 5 clots per menstrual cycle
Cramping relieved after passing clots
Do you ever experience vaginal dryness?
Do you notice fertile/ egg-white mucus around the time of ovulation?
Do you have any issues of excess, colored, or smelly vaginal discharge?
Frequent UTI?
Frequent yeast infection?
STI?
Do you have PMS? If so, check all that apply:
Starts a day or 2 before period
Starts 2-4 days before period
Starts 5-7 days before period
Starts 7-10 days before period
Starts basically after ovulation
Sudden drop of energy after ovulation
Includes headaches or migraines
Includes light headedness or dizzy spells
Includes fatigue
Includes extreme fatigue
Includes mood swings, especially weepiness
Includes mood swings, especially irritability
Includes rage
Includes night sweats or hot flashes
Includes breast distension, tenderness, or pain
Continues through first few days of period
I feel dramatically better as soon as I start bleeding
I feel even worse once I start bleeding
I feel better when I stop bleeding
I feel worse when I stop bleeding
Other:
Date of last pap smear?
Any abnormal Pap tests?
Age you first became sexually active
Pregnancy History:
Pelvic floor intake
Please check all that apply:
I checked yes to a urinary or bowel symptom above
I am aware of trauma to my pelvic floor
I suspect or a physician or health care worker suspects trauma to pelvic floor
I have low back or sacrum pain
I have difficulty descending my diaphragm
I have difficulty getting a full breath
I have pain with penetrative intercourse
I have issues with penetrative intercourse
I enjoy penetrative intercourse
I am able to orgasm
I have difficulty reaching orgasm
I have prolapse
Other:
Have you worked with a Fertility Doctor? If yes, complete the following 2 sections as applicable. If not, you can skip and I look forward to meeting with you!
Fertility Testing History
What is your most recent AMH level, and when was it tested?
What is TSH level?
What is your antral follicle count?
Have you ever had your fallopian tubes evaluated by hysterosalpingogram (HSG)?
Yes No I’m not sure
Have you ever had the inside of your uterus evaluated by a saline infused sonohystogram (SIS)?
Yes No I’m not sure
Have you ever had a hysteroscopy?
Yes No I’m not sure
Have you ever had a laparoscopy?
Yes No I’m not sure
A laparoscopy is a procedure where a small camera is inserted into the abdomen through a small incision. Another surgical tool is inserted through another small incision to provide air into the abdominal space and allow the camera to visualize structures within the abdomen and pelvis.
Have you had one or both of your Fallopian tubes removed?
Yes No I’m not sure
Have you had one or both ovaries removed?
Yes No I’m not sure
Have you had any other tests you think I should know about? Please provide name of the test or procedure, the results, and the date
Are there any surgeries I should know about?
Have you had any genetic testing?
Will you be using donor sperm
Yes No I’m not sure
Has the sperm you will be using been evaluated with a sperm analysis?
Yes No I’m not sure
When was the sperm last analysed or tested?
What was sperm count?
What was sperm motility?
What was sperm morphology?
Which criteria were used to assess the sperm?
Was the sperm acrosome tested?
Yes No I’m not sure
Was DNA fragmentation testing used?
Yes No I'm not sure
Reproductive Technologies History
Number of Clomid/Clomiphene citrate enhanced cycles:
Number of Femara/ Letrozole enhanced cycles?
Number of IUIs:
Number of IVF retrievals?
- To the best of your ability- Date, number of follicles retrieved, number fertilized, number making it to blastocyst, number PGT tested and good to go?
Number of IVF transfers?
- Date and result?
- To the best of your ability, do you remember lining thickness at last check before transfer?
Will you be using or have you used donor eggs? Check all that apply
Used
Will be using
Not sure
No
Do you have frozen embryos banked?
Were the embryos fertilized using Intracytoplasmic Sperm Injection (ICSI)?
Yes, all of the eggs were fertilized with ICSI
Yes, half of the eggs were fertilized with ICSI and half were not
No, none of the eggs were fertilized with ICSI
I'm not sure
How many embryos in total do you have in storage?
Were the embryos genetically tested or screened?
Are you planning a fresh IVF and embryo transfer?
- If yes, when are you planning to start the cycle?
Are you planning a 'freeze all' cycle?
- If yes, when are you planning to start the 'freeze all' cycle?
Are you planning a Frozen embryo transfer?
- If yes, when are you planning to start the frozen embryo transfer cycle?
Have you ever experienced Ovarian Hyperstimulation Syndrome (OHSS)?
Yes No I'm not sure
Have you ever had a cycle canceled?
Yes No I'm not sure
If yes, what was the reason for cancellation?
ovaries didn't respond well to medications
hyper stimulated
uterine lining was too thin
no viable sperm
eggs didn't fertilize
no embryos survived
Other
If other, please describe:
Are you planning a reciprocal IVF cycle and share co-maternity?
Yes No I'm not sure
Will you be using a gestational carrier (surrogate)?
Yes No I'm not sure
Is there anything else you think I should know?
Thank you for completing the forms. Please also complete the Health History. I look forward to meeting with you!