Client Intake
Welcome and congratulations for wanting to learn more about your amazing body!
Please fill out the following intake to help me get to know you and serve you better.  

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Email *
Date *
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Name *
What are your preferred pronouns?
Address *
Phone *
Date of Birth *
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Age *
Height *
Weight *
Are you content with your body as it is?
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Occupation *
Heritage *
Blood Type *
Where/From whom did you hear about me? *
GENERAL
Please answer the following questions about yourself!
What are your goals for our work together? *
What is your history with Cycle Tracking?   *
Are you in a supportive relationship? *
Is there anything you'd like to share with me about your sexual orientation that feels relevant? *
Are you currently cycling?  
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CHARTING
If you currently chart your cycle, please answer the following questions
Where/From whom did you learn to chart your cycle?
What does your temping practice look like? (Typical time of temp, temping daily? Before rising?)
What does your cervical fluid practice look like? (How often are you checking?  How do you check? How do you record?)
Do you track other signs of fertility?  If so, which?
How do you keep your information- paper chart? App?  
Do you have any questions about your charting practice? Perhaps, anything you'd like to be more clear?
CONTRACEPTION
Please share a bit about your history with contraception
What methods of birth control have you used in the past? *
Please share specific history of hormonal contraceptive use; types, years used, side effects *
List the date you last took hormonal contraceptives (month/year) *
What form(s) are you using currently? *
Do you have intentions to become pregnant either now or later? *
CYCLES- answer if you are currently cycling.  If not, feel free to answer in regards to past cycles
(cycle= entire cycle menses/ovulation/day one to day one) (menses= bleeding time)

When did your last period begin?
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How “regular” are/were your cycles (check one): *
Comments:
Are you already aware of your more fertile times? *
If currently tracking... how many days of cervical fluid do you normally observe each cycle?
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If currently tracking, please list the types of CF you regularly see.  Be explicit (example: lots of stretchy, goopy stuff, a little bit of gummy and some yellowish creamy)
MENSES
Please share about your bleeding time
Heavy / Medium / Light flow? *
Average length of bleeding time *
Do you see clots?  If so please describe. *
What pattern does your blood flow in? (for example: light, heavy, heavy, medium, spotting...) *
What color would you say your blood is?
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What does a 'heavy' day of bleeding look like to you?
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Are your periods painful? *
How would you rate the pain on a scale of 1-10? *
Not painful
Very painful
What other cyclical discomforts do you experience?  (such as PMS/headaches/etc) *
Which of these symptoms are most challenging?
What specific questions/comments or concerns do you have about your cycle? *
CONCEPTION
Answer if applicable
Pregnancies, Dates and Outcomes (includes live births, pregnancy losses and terminations) *
Any history of challenges with conception? *
Are you currently breastfeeding? *
Pre-Conception
Answer the following questions if currently aiming to conceive
Do you have any known conditions regarding your fertility?
Have you had any fertility testing done?  If so, what were the results?
Has your partner undergone fertility testing.  If so, what were the results?
How long have you been ‘trying’ to conceive and how actively?
GENERAL HEALTH
Please list any other reproductive health issues, past or present. *
Are you aware of what age your mother was when she experienced menopause?  
Do you have a history of reproductive issues in your maternal lineage?  If so, please describe
Have you ever had any cervical procedures? (colposcopy, LEEP, etc...)   *
Any history of abnormal paps? *
History of recurrent yeast infections, BV or other flora imbalances? *
History of STI’s or other infections? *
Do you use a lubrication during sexual relations and if so, what type?
Please list all other health issues or conditions (even if you think they wouldn’t be relevant) . *
Please list other 'symptoms' that you experience that are not associated with a diagnosed condition
Are you currently taking medications for these conditions?  Please list.   *
What would you say is your weakest system constitutionally?
What supplements and herbs do you regularly take? *
How would you rate your digestion? *
How often do you have a bowel movement and how would you describe it? (ex: hard pebble like, unformed...) *
How would you rate your dietary habits? *
What type of diet do you eat? (e.g., Omnivore,Vegan, WAPF, Paleo, etc.) *
Are there foods you avoid?  If so, what are they and why do you avoid them?
How much water do you consume each day on average and where do you source your water? (filter, tap, spring, well...) *
Do you consume caffeine and if so, in what form and how much/often?   *
Do you use recreational or prescription drugs?  If so, what type and how often?   *
What does a typical breakfast look like for you: *
What does a typical lunch look like for you?
What does a typical dinner look like for you?
What about snacks and drinks?
Do you eat organic foods?  If so, what percentage?
Do you have any significant chemical exposures due to work or living conditions? (example- living near orchards, house-cleaning with conventional products, etc...)
Do you have any known allergies (food or otherwise)? *
Do you have a history of extensive dental work?  Please explain.
Were you vaccinated as a child and have you received boosters as an adult?  Did this include the Gardisil vaccine?  
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Were you breastfed as a baby?  For how long?
How many hours of sleep do you get each night on average? *
How well do you sleep?  Any troubles? *
Do you have any lighting in your room while sleeping? (alarm clock, street lights, etc...)   *
How much screen time and during what hours of day? *
What is your stress level? *
Pretty chill life
Extremely stressed out
What stress relief tools do you utilize? *
How strong would you consider your libido (sex drive) to be?
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Are you happy with your current libido?  Would you like to discuss it?  
Do  you have meaningful relationships/connections in your life?
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Anything you want to share about this?
Do you feel you have the resources to receive the healthcare you desire?  
Please share what types and what frequency that you exercise: *
Have you had any significant traumas you’d like to mention? *
Do you receive regular bodywork or preventative care? *
Are you open to making dietary/lifestyle changes to shift your reproductive health? *
Consent Agreement
I understand that attending this consult/class does not guarantee that I or my partner will have the desired outcome we are seeking.  I further understand that if I have any questions or problems that I should contact my instructor or other health care practitioner.

I understand that using this method for contraceptive purposes, even when used correctly, can fail.  The FAM has been shown to be between 98.5 and 99.6 percent effective when practiced accurately (depending on the learning model and on the particular guidelines of the practice).  Most recent studies performed in Germany in 2007 (using similar but not identical guidelines to what is taught in this class) have given FAM a ‘perfect use’ rating of 99.4-99.6% and a ‘typical use’ rating of 98.2%, which takes into account that users are not always following the rules, observing correctly, charting consistently or using protection during the fertile time.

I claim full responsibility for my use of this method and the information received in this consult, as well as for my own health.  I further understand that any information disseminated in this class is for the purpose of education and is not intended to diagnose, cure or treat disease.

I thus release all liability of my teacher.



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Date
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Use of Material for Educational Purposes
I grant permission for Sarah Bly, FAE, and Grace of the Moon, to use my charts and client information to further FAM education in the world.  She may share my charts (anonymously) with future students while teaching.  My privacy will ALWAYS be respected and strict confidentiality will be upheld.

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