For Active Clients of Infinity Fertility.
Please Note: You will want to have your current chart handy when completing this form.
Shirelle Edghill, CFCP
Tawny Crawford, FCP
Stephanie Gavin BSN, RN, CCRN, FCP
Lisa Collard, FCP
Have you had a follow up in the last 6 months?
Client Number (found next to your name on the top of the back of your chart)
Full Address, including zip code.
Do you need a chart?
If you need a chart, which number chart are you CURRENTLY using (i.e. if you're using your first chart, type 1)
If you need stamps, which specific stamps do you need?
*******If you do NOT need a chart, you do not need to fill out the remainder of this form. *********
Current Instructions (Those that are circled on Back of Chart) - Check ONLY those which your Practitioner has currently assigned - If you are requesting a new chart, this MUST be filled out or we will not send your chart.
A. Always Keep to the Observational Routine
B. Chart at the end of the day, every day, and record the most fertile sign of the day
C. Avoid Genital Contact
D. Days of Fertility
D1.The menstrual flow
D2. From the beginning of mucus until 3 full days pask PEAK
D3. 1 or 2 days of NON-PEAK mucus PRE-PEAK
D4. 3 or more days of NON-PEAK mucus PRE-PEAK - PLUS count 3
D5. Any single day of Peak mucus - Plus count 3
D6. Any unusual bleeding - plus count 3
E. Days of Infertility
E1. Dry days pre-Peak - End of Day, Aternate days
E2. Dry days pre-Peak -End of day, every day
E3. 4th day post-Peak - Always end of the day
E4. Dry days post-Peak (after 4th day)- end of day, alternate days
E5. Dry Days Post-Peak (after 4th day)- end of day, every day
E6. Dry Days post-Peak (after 4th day)-- any time of day
E7. Dry days on L, VL, or B days of bleeding at the end of Menstrual flow- end of day
F. Seminal Fluid Instruction
G. "Double" Peak
G1. On P+3, ask "double" Peak questions
G2. If post-Peak phase is greater than 16 days in duration and system used properly to avoid pregnancy, anticipate "missed" period from "double" peak
G3. When ANTICIPATING "double" Peak, keep to the END of the infertile days & countinue good observations
H. When in doubt, consider yourself of peak fertility and count 3
I. Special Fertility Instructions
I1. Avoid genital contact until good mucus is present (Subfertility Only)
I2. Use days of greatest quanity and quality and first two days afterwards
I3. Record the amount of stretch of the mucus (Subfertility Only)
I4.Record abdominal pain (Subfertility Only)
J. Essential Sameness Question
K. Yellow Stamp Instructions
K1. Pre-Peak -- End of day, alternate days
K2. Post-Peak (After 4th day) - End of day, alternate days
K3. Post-Peak (after 4th day)- end of day, every day
K4. Post-Peak (after 4th day)- any time of day
K5. Discontinue use when period starts (BF)
K6. Discountinue pre-peak YS, in regular cycles when mucus cycle <9 days
L. If totally breastfeeding, first 56 days after birth are infertile
M. End of day instructions apply through the first normal menstrual cycle
O. Continue charting for duration of pregnancy
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