For the most accurate evaluation, please complete the form below
carefully and thoroughly. Your privacy will be strictly protected
(see our Privacy Policy).
It
should take you some time to complete this form properly so ensure you
have at least one hour to dedicate to this important information
gathering phase. When you are finished please click on the
"Submit" button at the bottom of the form.
PATIENT INFORMATION
I understand that I should be evaluated by a physician for the
condition I am requesting consultation. The diagnosis and
treatment plan I will be given by FHRHA is based upon Traditional
Chinese medical principles and natural treatment only, and does not
constitute a western medical diagnosis. I understand that I am not
to rely on Traditional Chinese diagnosis and treatment as my sole remedy
for the treatment I am seeking. I understand if no substantial
improvement is made in the condition for which I am seeking
consultation. I am to seek advice from a Western medial doctor.
Further, if I am concurrently undergoing Western medical treatments, it
is my responsibility to advise by physician of any herbal supplements I
am concurrently taking.
I have read and understand the above statement: Please type YES as your signature:
Today's Date:
How did you hear about us:
If reffered by a friend, who may we thank?
MEDICAL HISTORY
Major complaint /
health issue?
How did this condition develop?
How long has this condition
persisted?
What makes it better /
worse?
Have you seen a physician for the condition? If
yes, by whom and what was the diagnosis?
What medicine or treatment has your physician prescribed for the condition
& how
well did you respond to it?
Have you seen a Chinese herbal doctor or an acupuncturist for the condition?
Have you taken any herbal remedy for the condition? What are they, the dosage,
and for how long? How did you respond to them?
List all allergies:
List all medications you are currently taking (include dosage and for how long):
List all surgeries (include date and reason):
List all significant taumas (auto accidents, falls, etc...):
SIGNIFICANT ILLNESSES (PLEASE CHECK ALL THAT APPLY)
Arthritis:
Asthma:
Autoimmune: AIDS: Cancer
Diabetes: Gallstones: Heart Disease:
Age at which menstruation began:
Date of last menstrual period:
How many days are there from one period to the next?
How many days do you normally bleed?
Do you have painful Periods? How many days does the pain
last?
Is the bleeding light, normal, or heavy?Is there clotting?
What color is the blood? (light red,red, dark red, purple, brownish,
black).
Check only the boxes that apply to you (conditions
you have had or have):
Pre-menstrual tension (PMS):
Face breaks out during period:
Breast tenderness before period:
Spotting between periods:
Irregularly spaced menstrual cycles:
Abnormal PAP Smear:
Cervical biopsy, operation, cauterization, or conization:
Venereal disease:
Yeast infections:
If you
have checked any of the above boxes, please explain further: when
diagnosed, what medications you were treated with, and for how long.
Check only boxes that apply - If unchecked "No" is assumed
Have your cycles changed since they began?
yes
- If yes, how?
Do you ovulate on your own? yes
don't know -
On what day of cycle (if yes)
Breast tenderness at/during ovulation?
yes
Do you get premenstrual low back pain?
yes
Do your bowel movements become loose at the
beginning of your period?
yes
Do you have a partner with whom you have
been trying to conceive?yes
How long have you been married or living together?
Are you using donor sperm either because you have a female partner, or
your male partner has fertility issues?yes How long have you been trying to conceive?
Is your partner supportive of your wishes to conceive?yes
Have either of you had a Western medical diagnosis relating to
infertility?yes
If Yes above, what was it?
By whom?
Have you taken medication to help you ovulate?yes
What kind?
For how many cycles?
Have your fallopian tubes been evaluated medically?yes
What were the results, if yes?
Have you had any tubal operations?yes
Have you had any hormone laboratory test performed?yes
FSH Normal
High
Prolactin Normal
High
Thyroid Normal
High
Low
Progesterone Normal
High
Low
Testosterone Normal
High
Low
Other
Normal
High
Low
Have you ever had fertility treatments? (IVF, IUI, etc..)yes
What type, when, and what clinic?
How did you respond to the fertility treatment?
Poor
response Average/Good
response
Have you ever received chemotherapy or radiation?yes
How is your sexual desire (mental interest)
Low
Normal
High
How is your sexual arousal response (physically aroused/orgasm)?
Low
Normal
High
Do you use vaginal lubricants?yes
Are you more than 20% over your ideal body weight?yes
Do you exercise regularly?yes
Do you have a stressful occupation?yes
Do you have excessive facial/body hair?yes
Do you have excessive oily skin?yes
Have you experienced excessive loss of head hair?
yes
Female Fertility Worksheet - (check all
that apply)
KI YI-
Lower back weakness, soreness or pain, or knee problems:
Ringing in ears or dizziness:
Prematurely gray hair:
Dark circles around or under your eyes:
Night sweats:
Hot flashes:
Fearful:
KI YA-
Lower back pain premenstrually
Low back sore or weak
Cold feet, especially at night:
Colder than those around you
Low libido:
Often fearful
Wake up at night or early a.m. to urinate
Frequent profuse urination:
Profuse vaginal discharge Cold menstrual cramps responding to heat
SP-
Often fatigued:
Poor appetite:
Energy lower after a mealr:
Bloated after eating:
Crave sweets:
Loose stools, abdominal pain or digestive problems:
Cold hands anf feet:
Cold nose:
Feel heavy or sluggish:
Heaviness or grogginess in the head Bruise easily:
Poor circulation:
Varicose veins:
Lacking strength in arms & legs:
Lacking in exercise:
Prone to worry:
Low blood pressure:
Sweat easily:
Dizzy or lightheaded on standing:
Allergies, frequent colds:
Hypothyroid, Anemia:
Hemorrhoids or polyps:
More tired around ovulation More tired during menstruation Spotting before period Uterine prolapse Bearing down sensation cramping with
menstruation
BL X Menstrual blood dark:
Midcycle pain around ovaries:
Painful inmovable lumps on breast:
Menstrual blood contains clots:
Endometriosis or fibroids:
Piercing or stabbing menstrual cramps:
Varicose or spider veins:
Red hemangiomas (cherry red spots) on skin:
Chronic hemorrhoids:
Tender lower abdomen:
Lumps in lower abdomen:
Vascular abnormality or blood clotting disorder:
BL- Menses scanty or late:
Dry, flaky skin:
Prone to
Chapped lips:
Brittle nails:
Diminished nighttime vision:
Dizzy or lightheaded around period:
Menstrual cramps
toward end of period:
Hypothyroid or anemia:
LR-Q
Prone to emotional depression
Prone to anger/rage
Premenstrual irritability:
Bloated or irritable around ovulation
Breast tenderness around ovulation:
Premenstrual breast tenderness
Pain or discharge from nipple
Elevated prolactin levels:
Bloated premenstrually Difficulty falling asleep at night Heartburn or bitter taste in mouth Painful periods
Dark thick menstrual blood Menstrual cramps before or first day of period
H-
Wake up early & can't get back to sleep
Heart palpitations esp when anxious
Nightmares:
Low spirit/vitality
Agitation or extreme restlessness:
Fidgetting
Excessive sweating esp on your chest
Usually dry mouth and throat:
Thirsty for cold drinks:
Feel warmer than those around you:
Wake up sweating or have hot flashes:
Break out with red acne esp during menstruation:
Short menstrual cycle:
Vaginal irritation or rashes
Tired & sluggish after a meal:
Fibrocystic breasts:
Cystic or postular acne:
Urgent, foul smelling stool:
Menstrual blood with mucous:
Yeast infections and vaginal itching:
Achy joints upon movement:
Overweight:
Do you have other comments on your reproductive health?
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