Fertility Intake Fertility Intake "*" indicates required fields Patient InformationName* First Last Email* Date of Birth* MM slash DD slash YYYY Phone: Mobile*Phone: HomePhone: WorkCan we call you at work?* Yes No Sex:* Male Female Marital Status:* Single Married Divorced Widowed Seperated Minor Race:* Caucasian African American Asian Native American Latin American Other Ethnicity* Hispanic Latino Non-Hispanic / Non-Latino Occupation:Employer:Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about our practice?*Emergency contact Name* First Last Relationship to the Patient:Relation Phone numberAccident InformationIs this visit due to an accident?* Yes No What type?* Auto Work Other Has it been reported?* Yes No To whom?* Auto Work Other Insurance InformationPolicy Holder NameDate of Birth: Policy Holder MM slash DD slash YYYY Social Security NumberMember ID NumberGroup NumberCustomer Service/Provider Number located on back of cardThis field is hidden when viewing the formRelationship to the Patient:This field is hidden when viewing the formRelation Phone numberThis field is hidden when viewing the formDo you have health insurance? Yes No This field is hidden when viewing the formName of Carrier:This field is hidden when viewing the formDo you have secondary insurance? Yes No This field is hidden when viewing the formName of Carrier:PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S)Assignment and Release (insured patients)I certify that I (or my dependent) have insurance coverage with and I AUTHORIZE, REQUEST AND ASSIGN MY INSURANCE COMPANY TO PAY DIRECTLY TO THE PHYSICIAN/MEDICAL PRACTICE, INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary, including the diagnosis and the records of any exam or treatment rendered to me, in order to secure the payment of benefits. I authorize the use of this signature on all insurance claims, including electronic submissions.SIGNATURE (X)Date MM slash DD slash YYYY Menstrual HistoryAge at which Menses beganAge at which it stoppedAre your periods painful? Yes No How many days does the pain last?How many days do you normally bleed?How heavy is the bleeding? Light Normal Heavy What color is the blood? Light red Red Dark Red Brown Black Is there clotting? Yes No Do you have premenstrual tension? Yes No Does your face break out before or during your period? Yes No Do your breasts become tender premenstrually? Yes No Do you retain water during your period? Yes No Do you bleed or spot between periods? Yes No Are your menstrual cycles spaced irregularly? Yes No How many days are there from one period to the next?Date of last menstrual period MM slash DD slash YYYY How many pregnancies have you had?How many children do you have?How many abortions have you had?How many miscarriages have you had?How many times has a D&C been performed?Complications?Have you ever had an abnormal pap smear? Yes No Have you ever had a cervical biopsy, operation, cauterization or conization? Yes No Have you ever had a venereal disease? Yes No Do you get yeast infections regularly? Yes No Have you ever been diagnosed with a chlamydial infection? Yes No Do you have chronic vaginal discharge? Yes No Do you have any sores on your genitalia? Yes No Have you ever had pelvic inflammatory disease? Yes No Were you treated for it? Yes No How?Date of last Pap SmearHave you ever been diagnosed with uterine fibroids or polyps? Yes No Have you ever been diagnosed with endometriosis? Yes No Have you been diagnosed with pelvic adhesions? Yes No Have you been diagnosed with any pelvic abnormalities? Yes No Have you taken any medications other than contraceptives for gynecological conditions?MedicineReasonHow longHave your cycles changed since they began? Yes No How?Do you ovulate on your own? Yes No On what day of your cycle?Do your breasts get tender at/during ovulation? Yes No Do you get premenstrual low back pain? Yes No Do your bowel movements become loose at the beginning of your period? Yes No Fertility HistoryHow long have you been trying to conceive?Is there a history of infertility in your family? Yes No DescribeHave you had fertility treatments? Yes No If Yes, when and where?By Whom?What types?Have you taken medication to help you ovulate? Yes No When?How long?Have your fallopain tubes been evaluated medically? Yes No What were the results?Have you had any tubal operations? Yes No Have you had any hormone laboratory tests performed? Yes No What were the results?Do you have a single partner with whom you have been trying to conceive? Yes No How long have you been married or living together?Has he had a fertility workup? Yes No What were the results?Is your partners supportive of your wish to conceive? Yes No Have you taken oral contraceptives? Yes No When?How long?Have you ever had an IUD? Yes No When?How long?Have you ever taken DepoProvera? Yes No When?How long?Have you had a diagnosis relating to infertility? Yes No What was it?How is your sexual energy? Low Normal High Are you experiencing any sexual problems? Yes No Does your partner experience any sexual dysfunction? Yes No Do you douche regularly? Yes No With what?Do you use vaginal lubricants? Yes No Are you more than 20% over your ideal body weight? Yes No Are you more than 20% below your ideal body weight? Yes No Do you have a stressful occupation? Yes No Do you exercise regularly? Yes No Do you have excessive facial hair? Yes No Do you have excessively oily skin? Yes No Have you experienced excessive loss of head hair? Yes No Have you noticed discharge from your nipples? Yes No Was your mother exposed to diethylstilbestrol (DES) when she was pregnant with you? Yes No Have you been exposed to any known environmental toxins or hormones? Yes No Are you presently taking steroids? Yes No Informed Consent to CareNatural Life Acupuncture and Kinesiology A patient coming to the doctor gives him/her permission and authority to care for them in accordance with appropriate test, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare case, underlying physical defects, deformities or pathologies may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician. This office does not perform breast, pelvic, prostate, rectal, or full skin evaluations. These examinations should be performed by your family physician, GYN, and dermatologist to exclude cancers, abnormal skin lesions that should undergo biopsy/removal or other treatments.. We also do not prescribe or refill ANY controlled substances. All prescriptions should be refilled by your original prescriber and any new prescriptions should be issued by your primary care provider. The patient assumes all responsibility/liability if the patient does not report on health forms any past medical history, illnesses, medicines, or allergies. I agree to settle any claim or dispute I may against or with any of these persons or entities, whether related to the prescribed care or otherwise, will be resolved by binding arbitration under the current malpractice terms which can be obtained by written request. Acupuncture care, like all forms of health care, while offering considerable benefit may also provide some level of risk. This level of risk is most often very minimal, yet in rare cases injury has been associated with acupuncture care. The types of complications that have been reported secondary to acupuncture care include bruising, bleeding, tingling, strong sensation at location of needle insertion. One of the rarest complications associated with acupuncture care is lung or organ puncture. I wish to rely on the doctors judgement based on the facts known at this time. Prior to receiving acupuncture care in this office, a health history and physical examination will be completed. These procedures are performed to assess your specific condition, your overall health and, in particular, your whole body health. These procedures will assist us in determining if acupuncture care is needed, or if any further examinations or studies needed. In addition, they will help us determine if there is any reason to modify your care to provide you with a referral to another health care provider. All relevant findings will be reported to you along with a care plan. This notice is effective as of the date it is signed and will expire seven years after the date on which you last received servies from us. Patient SignACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESPatient NameDate MM slash DD slash YYYY I acknowledge that I have reviewed the Notice of Privacy Practices of Natural Life Acupuncture and Kinesiology. (Please initial one of the following options and sign below.) I do not request a copy of the Privacy Notice at this time. I acknowledge that I can request a copy at any time and the Privacy Notice is posted in the office. Please initial below: I acknowledge that it is the policy of this office to leave reminder messages on my answering machine or with another person in my home. I may make a request of an alternative means of communication (within reason) in writing. I acknowledge that if I should have a problem or question in regard to my rights, I may speak with the staff about my concerns. Signature of Patient/GuardianDate MM slash DD slash YYYY Witness (Office Staff)Date MM slash DD slash YYYY CONSULTATION HISTORY:”What symptoms are you suffering with?How long have you had it?What does it feel like?Is there an earlier accident/ injury/ repetitive motion that is related to these problems? (i.e. Fall, auto injury, work injury, sports injury, repetitive motion on the job).Since the time you began suffering with this problem, what have you tried? .(i.e. Ice, Heat, Rest, Over the Counter Meds, Prescriptions, P.T., Chiro. other)What activities do you have trouble doing because of these symptoms?Looking forward a few years from now, what are those things you wish to be doing more of? (i.e. travel, relationship, work, physical…)On a scale of 1-10, ten being the highest, rate your commitment to getting rid of the problem.Is there anything preventing you from getting this problem taken care of?Notes:CAPTCHANameThis field is for validation purposes and should be left unchanged.
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