Fertility/Women’s Health Acupuncture/ Intake Form NameField is required!Field is required!AgeField is required!Field is required!Select a dateField is required!Field is required!Home AddressField is required!Field is required!CityField is required!Field is required!StateField is required!Field is required!ZipField is required!Field is required!Home PhoneField is required!Field is required!Work PhoneField is required!Field is required!E-mailField is required!Field is required!BirthdateField is required!Field is required!If under 18, person responsible for your accountNameField is required!Field is required!Emergency ContactNameField is required!Field is required!Contact PhoneField is required!Field is required!OccupationField is required!Field is required!GenderField is required!Field is required!HeightField is required!Field is required!WeightField is required!Field is required!Whom should we thank for referring you to our office?Field is required!Field is required!Have you had acupuncture therapy before?YesNoField is required!Field is required!With Whom?Field is required!Field is required!Please indicate if any of the following pertain to you: (marking “yes” does not make you ineligible for treatment, however, it may restrict some of our treatment modalities):HepatitisHIVSeizuresPacemakerBlood-Thinning MedsPregnancyField is required!Field is required!Please indicate the use and frequency of the following:CoffeeField is required!Field is required!Soda popField is required!Field is required!WaterField is required!Field is required!AlcoholField is required!Field is required!Recreational drugsField is required!Field is required!TobaccoField is required!Field is required!Please list any prescription or over-the-counter medications you are presently taking:Any prescription or over-the-counter medications you are presently taking...Field is required!Field is required!Reasons For Medication...Field is required!Field is required!What are the health problems for which you are seeking treatment?Field is required!Field is required!How long have you had this condition?Field is required!Field is required!What other forms of treatment have you sought?Field is required!Field is required!What helps your condition?Field is required!Field is required!What aggravates your condition?Field is required!Field is required!Please list any surgeries or major health incidents (accidents, etc.) in your lifeField is required!Field is required!What would you like to achieve with acupuncture treatment?Field is required!Field is required!Please “check” the symptoms or conditions you experience frequently: excessive appetiteinsomniacoughlow back paineye problems loose stool/diarrhepalpitationsshortness of breathknee problemsjaundicedigestive problemscold hands and feetdecreased sense of smellhearing impairmentdifficulty digesting oily foodsindigestionvomitingnightmaresnasal problemsear ringinggall stonesbelching, burpingmentally restless skin problemskidney stones light-colored stool heartburn/refluxlaughing for no reasonclaustrophobia decreased sex drive soft or brittle nailsstomach bloating chest paincolitis/diverticulitishair losseasily angeredobsession in workpoor memoryconstipationurinary problemdifficulty in relationships, making decisions, etc lack of appetite sadnesshemorrhoidsdental problems high cholesterolrecent use of antibioticsbitter tastefatigueedemaasthmaallergiesdizzinessget sick easilyheadachesI usually feel warmI usually feel chilledField is required!Field is required!Age of first periodField is required!Field is required!Date of last periodField is required!Field is required!Number of childrenField is required!Field is required!Number of days between periods (your cycle)Field is required!Field is required!Number of days of flowField is required!Field is required!Color of flowpale/light red redbright reddark reddark red/brownField is required!Field is required!Amount of flowspottinglighteven throughoutheavyclotsField is required!Field is required!# of pads you use per day:# of pads you use per day:Field is required!Field is required!1 st dayField is required!Field is required!2 ND dayField is required!Field is required!3 RD dayField is required!Field is required!4 th dayField is required!Field is required!+daysField is required!Field is required!Other symptoms related to menses: DischargePMSHeadacheNauseaConstipationDiarrheaSwollen Breasts Mood SwingsIncreased AppetiteDecreased AppetiteInsomniaField is required!Field is required!Have you ever been diagnosed with: fibroidsfibrocystic breastsendometriosisovarian cystsPID polycystic ovary syndromeSTDField is required!Field is required!Please indicate if the following pertain to you:Do you have ringing in your ears?Is your hair prematurely gray? Do you have vaginal dryness?Is your mid-cycle cervical mucus scanty or missing?Do you have dark circles under your eyes?Do you have night sweats?Are you prone to hot flashes?Would you describe yourself as “afraid” frequently?Do you have dizziness?Do you have knee problems?Do you have low back pain pre-menstrually?Is your back sore or weak?Are your feet cold, especially at night? Are you typically colder than those around you?Is your libido low?Are you often fearful?Do you wake up at night or early in the morning because you have to urinate?Do you have early morning loose, urgent stools?Do you have profuse vaginal discharge?Do you feel cold cramps during your period that respond to a heating pad?Are you often fatigued?Do you have poor appetite?Is your energy low after a meal?Do you feel bloated after eating?Do you crave sweets?Do you have loose stools, abdominal pain, or digestive problems?Are your hands and feet cold?Are you prone to feeling sluggish?Are you prone to heaviness or grogginess in the head?Do you have varicose veins?Are you prone to worry?Have you been diagnosed with low blood pressure?Do you sweat a lot without exerting yourself?Do you feel dizzy or light-headed, or have visual changes when you stand up fast?Is your menstruation thin, watery, profuse, or pinkish in color?Are you more tired around ovulation or menstruation?Do you ever spot a few days or more before your period comes?Have you ever been diagnosed with uterine prolapse?Are your menstrual cramps accompanied by a bearing down sensation in your uterus?Are you often sick, or do you have allergies?Have you ever been diagnosed with hypothyroid or anemia?Do you have hemorrhoids or polyps?Are your menses scant or late?Do you have dry, flaky skin?Are you prone to getting chapped lips?Are your fingernails or toenails brittle?Are you losing hair on your head?Is your hair brittle or dry?Do you have diminished nighttime vision?Do you get dizzy or light-headed around your period?Are your lips, the inner side of your lower eyelids, or tongue pale in color?Is your menstrual flow ever brown or black in color?Do you feel mid-cycle pain around your ovaries?Do you have painful, unmovable breast lumps?Do you experience periodic numbness of your hands and feet, especially at night?Do you have varicose or spider veins?Do you have red cherry spots (hemangiomas) on your skin?Do you have chronic hemorrhoids?Does your menstrual blood contain clots?Have you been diagnosed with endometriosis or uterine fibroids?Do you have piercing or stabbing menstrual cramps?Do you have dark spots in your eyes?Have you been diagnosed with any vascular abnormality or blood clotting disorder?Are you prone to emotional depression?Are you prone to anger and/or rage?Do you become irritable premenstrually?Do you feel bloated or irritable around ovulation?Does it feel as if your ovulation lasts longer than it should?Are your breasts sensitive/sore at ovulation?Do you experience nipple pain or discharge from your nipples?Do you have a lot of pre-menstrual breast distension or pain?Do you become bloated pre-menstrually?Are your pupils usually dilated and large?Do you have difficulty falling asleep at night?Do you experience heartburn or wake up with a bitter taste in your mouthAre your menses painful?Do you feel your menstrual cramps in the external genital area?Is your menstrual blood thick and dark, or purplish in color?Do you wake up early in the morning and have trouble getting back to sleep?Do you have heart palpitations, especially when anxious?□ Do you have nightmares?Do you seem low in spirit or lacking vitality?Are you prone to agitation or extreme restlessness?Do you fidget?Do you sweat excessively, especially on your chest?Are your mouth and throat usually dry?Are you often thirsty for cold drinks?Do you often feel warmer than those around you?Do you wake up sweating or have hot flashes?Do you breakout with red acne, especially pre-menstrually?Do you have a short menstrual cycle?Do you have vaginal irritation?Do you feel tired and sluggish after a meal?Do you have fibrocytic breasts?Do you have cystic or pustular acne?Do you have urgent, bright, or foul-smelling stools?Does your menstrual blood contain stringy tissue or mucus?Are you prone to yeast infections and vaginal itching?Are you overweight?Do you have a wet, slimy tongue?Does your body feel like a barometer? Can you sense when it will rain?Field is required!Field is required!Fertility Information# of IVF proceduresField is required!Field is required!# of IUI proceduresField is required!Field is required!# of pregnanciesField is required!Field is required! #of miscarriagesField is required!Field is required!# of live birthField is required!Field is required!Has a physician diagnosed a difficulty with fertility due to: Female FactorMale FactorUnexplainedOtherField is required!Field is required!If Other Elaborate...Field is required!Field is required!Please check which services you would be interested in: Chinese herbal medicineTherapeutic massageTai chi Qi gong health exercises Relaxation techniquesNutritional consultationField is required!Field is required!In order to maintain the integrity of our practice, Golden Valley Acupuncture Center must request that all cancellations be made prior to within 24 hours of your appointment. Failure to provide at least a 24 hour notice or failure to show for an appointment will result in your account being charged for the full price of the visit.*THANK YOU FOR YOUR UNDERSTANDING.PRINT NAME:Field is required!Field is required!Select a dateField is required!Field is required!Signature:Field is required!Field is required!Submit
