Fertility Health History
Thank you so much for booking an appointment at the Acupuncture and Chinese Medicine Clinic. Please fill out this form before your appointment so we can get a better understanding of your current health condition. Allow 30-45 minutes to fill out the form, and read the directions carefully. If you prefer to submit a physical copy instead you can find our PDF form to print out on our website acmcenter.com and you may print it out and bring in the completed form during your appointment. If you have any questions on the form please don't hesitate to reach out via email office@acmcenter.com.

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Full First & Last Name *
Are you a patient or partner? *
Gender *
Age *
Date of Birth
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DD
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YYYY
Today's Date
MM
/
DD
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YYYY
What are your expectations for this visit? *
How many months have you been having intercourse without any form of birth control? *
What is your menstrual cycle pattern? Select all that applies.
If you selected no period, at what age did you stop having them?
If you selected bleeding, how many days of bleeding do you have during your periods?
Dates of 1st day of your last 2 menstrual periods
How many days are between periods?
How many periods do you have per year?
Do you need medication to bring on a period?
Clear selection
If yes, what are the medications?
Total number of ALL pregnancies
Number of abortions
How many children have you had?
Number of full term deliveries
Number of miscarriages (<20wks)
Number of premature (<37 weeks deliveries)
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