Name (Female Patient)
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First Name
Last Name
Email
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Phone
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(###)
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name of GP Surgery
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Emergency Contact
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Do you have allergies
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What are your allergies?
Please list all of your current medications and supplements
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Please add supplement brand
Have you been diagnosed with any of the following conditions.
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Please include past or present
Please explain - include diagnosis year and treatment plan:
If you suspect that you have one of the conditions above, please explain:
What age did you have your first period?
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If known, what day are you on within your menstrual cycle?
Note: Day 1 is the first day of your menstrual bleed (period)
MM
DD
YYYY
If known, when did you last ovulate?
MM
DD
YYYY
Do you experience menstrual bleeding or spotting outside of your actual period time?
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Please explain
Do you experience an increase of body temperature during day 1-5 of your menstrual cycle?
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Do you experience any of the following prior to your period?
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During peak ovulation time, please pick one option that best describes the appearance and sensation of your cervical mucus
If applicable, how many previous pregnancies have you had?
0
1
2
3
4
5
6
7
8
9
10 plus
Have you had any previous gynaecological surgeries?
Please include gynaecological surgical investigations
How long have you been trying to get pregnant?
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My periods are....
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Please choose one option
Number of days within your menstrual cycle?
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If your cycle is erratic and short. Please state how many days is within your shortest cycle
If your cycle is erratic and long. Please state how many days is within your longest cycle
Have you had a hormone panel blood test?
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Please provide any results given for your AMH, FSH. LH, Oestradiol, Progesterone, testosterone, prolactin levels
Do you have a physical condition that require regular use of non-steroidal anti-inflammatory drugs (NSAIDs) medication?
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Do you have any other medical condition or experienced any serious injuries?
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Please include past and present plus year of diagnosis
Temperature: I normally feel
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Digestion: I normally experience
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Urinary function: I typically experience
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Sleep: I experience
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Stamina & Energy: I normally feel
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Mental Health & Support: I feel that I can openly talk about my fertility journey to
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My partner about our shared fertility journey
My family
My friends
Medical professionals (GP, Nurse, Consultant)
My employer
My colleagues
How would you describe your general hopefulness towards attaining your fertility goals
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Do you do any of the following to support your mental health?
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Choose all applicable
Trish O Hara Acupuncture is a 'shame and judgement free' acupuncture clinic. You will not be asked about addictions (Tobacco, Alcohol, recreational drugs). I understand that these addictions may impede my fertility efforts. if I need extra support in these areas, that I can ask for that support at any time during your treatment or via phone, email or text.
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Trish O Hara Acupuncture does not ask about obesity, as overweight people can get pregnant relatively quickly and have healthy babies. More often than not, being overweight can be a symptom of PCOS, thyroid issues, sluggish digestion etc... However being overweight is not the cause of infertility. It is typically just a symptom. However I understand that I can ask for support at any time during treatment or via phone, email or text.
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Please note: Many women have experienced 'weight shaming' by medical professionals when it comes to gynaecological surgical investigations. If you have experienced this, then I invite you to think differently. More often than not weight shaming is more of a reflection of the surgeon's experience and confidence with working with different body types rather than you personally. If the option is available to you, please aim to work with a different consultant.
I consent to receiving acupuncture and biomagnetic heat lamp, Moxibustion (heated Chinese smokeless herb), massage, cupping, guasha and/or dietary information according to the principles of Traditional Chinese Medicine (TCM), to support my fertility efforts (diet focus: supporting fertility hormones and overall constitution). I understand that I can say no to any part of my treatment plan and remove my consent at any time.
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I understand that side effects of my treatment with Trish O Hara Acupuncture may include bruising or small haematomas at the insertion site and/or dull achy feeling at the insertion site. I understand that these effects are typically self limiting.
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If feel achy or bruise easily and/or bruises bother you, many clients have found benefits in using Arnica cream on the bruised site.
I understand that the desired effect of Cupping, is bruising that is typically painless and self-limiting.
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I understand that I must inform Trish O Hara Acupuncture immediately if I become pregnant during my treatment period as my treatment plan will change significantly.
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I will inform Trish O Hara Acupuncture if I have a pacemaker fitted
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I understand that it is normal to feel fatigued after my first acupuncture session. This is self limiting and should have resolved within hours or a couple of days.
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Aim to plan for a relaxing day after your first acupuncture session. Avoid vigorous exercise.
I understand that a course of acupuncture treatment is 6 sessions. Fertility clients may need 1-3 courses of treatment to meet their fertility goals and depending on personal medical history and situation.
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Results are not guaranteed.
