New Patient Intake Form

Instructions: the purpose of the intake is to be able to look at information regarding all the systems of the body. This gives us clues to imbalances that affect fertility but also show up as symptoms elsewhere in body and mind.

When filling out the systems review please check any boxes that apply to you now or at any previous time in your life.

Contact Us

Name *

First

Last *

Last

Birthdate *

Age *

Phone *

Email *

How did you find out about Health Solutions? *

Primary Health Care Provider *

Fertility Specialist (if applicable)

Medications Currently Taking

Supplements Currently Taking

Family Health History (mother, father, siblings, grandparents)

Have you ever been pregnant in the past? *

Yes

No

If yes, how long ago?

How long have you currently been trying to get pregnant? *

Has your male partner been evaluated for sperm quality?

Yes

No

If so, are there any issues?

Do you have a medical diagnosis for your fertility issue? *

Yes

No

Check any diagnosis that may apply. *

Ovarian Insufficiency

Amenorrhea (no periods)

Irregular Periods

Endometriosis

Polycystic Ovarian Syndrome

Fallopian Tube Damage or Blockage

Uterine Polyps or Fibroids

Cervical Mucus Issues

Hormonal Imbalances

Other

Systems Review

Menstrual Cycle *

I have regular periods

Irregular Periods

Amenorrhea (no periods)

PMS

Dysmenorrhea (pain cramping)

Endometriosis

Other

Days Between Periods *

Menstrual Blood Quality *

Clotting

Heavy Flow

Prolonged Bleeding

Light flow or scanty

Other

Ovulation/Ovarian Health *

Polycystic Ovaries

Low ovarian reserve

If you track ovulation, are there any irregularities?

Early ovulation

Late ovulation

No

Other

Endocrine Health *

Perimenopause

Hot Flashes

Hypothyroid

Hyperthyroid

Diabietes

Other

List Autoimmune Conditions

Blood Values (Do not check if unknown)

FSH

LH

Estradiol

Progesterone P4

Thyroid T4

Thyroid Stimulating Hormone (TSH)

Internal temperature: *

Normal

Cold extremities

Chilly throughout

Warm/hot

Flushes of heat

Heat at Night

Sensitivity to weather, I feel worse in: *

Cold

Hot

Damp

Dry

Mind/Emotions *

Stress/Frustration

Anxiety

Bipolar

Anger

Fear

Psychosis/Schizophrenia

Depression

Poor Memory

Attention Deficit

Other

Sleep *

Insomnia

Wake Unrested

Sleep Apnea

Difficulty Falling Asleep

Difficulty Staying Sleeping

Excessive Dreaming

Nightmares

Night Sweats

Other

Head *

Headaches

Tinnitus/Ringing

Migraine

Poor Vision

See Floaters

Hearing Loss

Abnormal Hair Loss

Dry Hair

Oily Hair

Cold Sensitivity

Flushes of Heat

Other

Respiratory *

Frequent Colds

Sinusitis

Bronchitis

Allergies

Asthma

Chronic Sore Throat

Chronic Phlegm

Chronic Cough

Other lung diseases

Circulatory *

High Blood Pressure

Low Blood Pressure

Anemia

Abnormal Bleeding

Chest Pain

Blood Clots

Cold Extremities

Numbness/Tingling Extremities

Irregular Heart Rhythm

Palpitations

Other

Heart disease type

Digestive *

Poor Digestion

Excessive Appetite

Constipation

Bloating

Ulcers

Hard Stools

Tired after eating

GI Bleeding

Loose Stools

Acid Reflux

Colitis

Frequent Diarrhea

Weight Gain

Irritable Bowel

Hemorrhoids

Abnormal Weight Loss Hepatitis

Nausea

Other

Urinary

Prone to bladder or kidney infections

Interstitial Cystitis

Painful Urination

Frequent Urination

Dark or Scanty Urine

Bloody Urine

Urinary Incontinence

Kidney Disease

Other

Dermatology *

Eczema

Psoriasis

Dry Skin

Oily Skin

Roseacea

Brittle Nails

Dry Hair

Skin Infections

Other

Musculoskeletal Conditions (list) *