Consultation intake form

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Name *

Phone *

Email *

Mailing address *

Preferred contact method? *

If it is something not listed above, please add any information here.

Who may I thank for your referral? *

Birth Date *

YYYY

Height *

Weight *

Past contraception use *

Please include method and approximate time period/years

Indicate your goals of charting *

Check any that apply

Trying to avoid

Trying to conceive

Will be trying to conceive

Hormonal health/monitoring

Other:

Required

Have you been charting? If so, since:

Length of cycles (range)

If you don't know, please indicate that

Age of first menses

If you do not know, please indicate that

Number of pregnancies

Number of births

Number of abortions

Check any you are dealing with

Cramps

Heavy Bleeding

Vulvovaginal pain

Painful intercourse

Frequent UTI

Clotting

Irregular bleeding

Irregular discharge

PMS

Other:

Do you have any known conditions such as PCOS, endometriosis, fibroids or ovarian cysts?

Please list anything you think may be relevant

Please list any medications you are on including herbs, hormones, and vitamins

Alcohol/nicotine/marijuana/caffiene/pain killers/antibiotics?

Please list the type and frequency, if they were in the past please list when.

Any past surgeries, especially anything vulvovaginal?

Known allergies or sensitivities?

Any history with STIs?

Any gynecological conditions in your family?

Typical exercise or activity

Typical diet

Are you under a lot of stress? Generally relaxed?

Sleep

How much do you get on a regular basis and does it feel sufficient? Do you sleep in absolute darkness? What time do you go to bed and wake up? Do you have a hard time falling asleep or staying asleep?

Is there anything else you think might be relevant? Do you have a primary concern?

Disclaimer

While I will educate you in how to use the sympto-thermal method of birth control, pregnancy, achievement, or assessing hormonal health, ultimately you assume all risk and liability about using this information. I do not make any warranty about how this information will work for you. I shall not in any way be held liable for any damage suffered by any person choosing to use any of the information that I teach. While the sympto-thermal method is a highly accurate form of birth control, as with any other method it is not foolproof and there is a chance that the method will fail. I will not be held responsible for any failure of the method. All verbal and written information, in the context of our professional relationship, will be kept confidential. I will not share information concerning you including the fact that you see me as a client. I will anonymously use information concerning you for purposes of research, teaching, public lecture, or publication with your written consent.

I understand and agree to the above mentioned statements

Optional: I allow my history and charting information to be used anonymously for research, teaching, public lecture, or publication.

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