Acupuncture & Homeopathy of Hingham Fertility Worksheet - Acupuncture & Homeopathy of Hingham

Date*

Name*

First Last

Age*

Fertility Doctor/Reproductive Endocrinologist:*

Fertility clinic:*

Western Medical Diagnosis:

How long have you been trying to conceive?

Western Diagnostic Tests

Check all that apply and give Dates

Thyroid Test

Date

Clomid Challenge

Date

Hormonal Levels: FSH, LH, Estradiol, etc.

Date

Endometrial Biopsy

Date

Hysterosalpingogram

Date

Hysteroscopy

Date

Ultrasound

Date

Genetic Screening

Date

Please check any Diagnoses below that apply:

Check all the below that apply and please give dates

Ectopic pregnancy

Date

Miscarriages

Date

Abortion

Date

D & C

Date

Abnormal Pap

Date

Has your husband/partner been checked for sperm quality?

Yes
No

Do you get: Recurrent yeast infections?

Yes
No

Do you get: UTI’s?

Yes
No

Have you ever had Chlamydia or any STD’s?

Yes
No

Date of Last Menstrual Period?

Yes
No

IUI: Dates and Outcomes:

IVF: Dates and Outcomes:

Is there any other information that may be helpful?

Fertility Worksheet

Fertility Treatment Form

Western Diagnostic Tests

Check all the below that apply and please give dates