TCM

Fertility

Male partner

Your cycle

Reproductive health history

Pain / injury

Please tell us about your condition

Male fertility

Male fertility

Reproductive health history

Lifestyle factors

In the past week, have you been feeling any of the following:

Personal details

Name: Dr Vitalis Acupuncture Auckland
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Datestamp

DD slash MM slash YYYY

Token number*

What best describes your situation?

I'm a new patient

I've completed this more than 6 moths ago

I'm addressing a new health issue

Which of the answers below is the closest match to the main issue you'd like to address?*

Please choose the issue that is most important to address first.

Injury or pain

Fertility (I'm a female patient)

Fertility (I'm a male patient)

Women's health (not trying to concieve)

Stress / anxiety / depression

Other

Date of birth:*

Day _ _

Month _ _

Year _ _

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Age

Your age is calculated from the date of birth above

Sex at birth

Female

Male

Other

Ethnicity

Which ethnic group do you belong to? Please select all that apply

NZ Maori

NZ European

Chinese

Indian

Other Asian

Latin American

Middle Eastern

European

African

Other

Work status

Employed Full-Time

Employed Part-Time

Homemaker

Disabled

Retired

Student

Prefer Not to Answer

Occupation

In case you're not currently employed, please tell us your past occupation which may have an influence on your current health.

Marital status

Single

Married or De Facto

Divorced

Widowed

Other

Your GP and / or Specialist

Your GP's name and phone number (or address/name of the clinic)

Height (in centimetres)

Weight (in kilograms)

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BMI

Do you suffer from allergies

Yes

List any allergies you have

Current medications

name of medication/dose/reason for taking. Please include herbal medications and any supplements in therapeutic dose.

Do you consume any of the following

Physical activity

Please tick all that apply

My job is physically demanding

I exercise more than 10 hours a week

I exercise 4 to 10 hours a week

I exercise 1 to 4 hours a week

I exercise less than an hour a week

I hardly get any exercise

Medical history

select all that apply (including relevant family history)

no medical history

cardiac

cancer

ears, eyes, nose, throat

endocrine

gastrointestinal

genitourinary

musculosceletal

hepatic

neurologic

respiratory pulmonary

psychiatric

sepsis

vascular

other

Medical history detail

Please briefly detail the medical history you have ticked above

Stress?

please tick any that apply

yes, stressed at work

yes, stressed at home

I suffer from anxiety

Please rate your stress level over the last few weeks

Low

Medium

High

Extreme

Please rate your anxiety level over the last few weeks

Low

Medium

High

Extreme

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Your sleep

	Usually	Sometimes	Rarely
I am satisfied with my sleep
I wake up rested
I spend less than 30 min awake at night, including the time it takes to fall asleep
I stay awake all day without dozing
I am normally asleep between 2am and 4am
My sleep is undisturbed by dreams

How many hours of sleep do you normally get each night?

I work night shifts

Yes

Other

I feel happy, calm/balanced

Most of the time

Only several days a week

Not at all

I feel fatigued

Almost never / only when I work too much

Only several days a week

Not at all

Appetite

Normal

Excessive

Lack of appetite

Specific food cravings

Bowel motion

Normal

Frequent constipation

Frequent loose stools

Alternating constipation & loose stools

Thirst

Normal

Other

Perspiration

Normal

Other

In a room with other people I normally feel

Colder than others

Warmer than others

Nor colder nor warmer

Headaches

How often do you suffer from headaches?

Never

Every day

Once a week

2 to 3 times a week

Once a month

2 to 3 times a month

Less than once a month

Other

Headaches intensity

Intensity 1 slight pain to 10 pain so severe you can't tolerate

Headaches: Location

Tick all that apply

Entire head

Frontal / forehead

Vertex / top of the head

Temporal / temples

Behind the eyes

Occipital (back of the head)

Did you get a menstrual bleeding in last 90 days?

Yes

What is the date of your last period? Do you know the reason your cycle stopped?

Are you trying to conceive?

Yes

Yes, in the near future

How long have you been trying?

Did you or your partner have a diagnosis related to infertility?

Yes

Diagnosis:

Did your/your partners' diagnosis include any of the following (tick all that apply)

unexplained infertility

advanced maternal age

PCOS

anovulation

blocked Fallopian tubes

fibroids or polyps

endometriosis

pelvic adhesions

pelvic abnormalities

male factor infertility

History of fertility treatments:

Have you had any of the following treatments

No previous treatment

Clomophene/Clomid or Letrozole

IUI

DI (donor insemination)

IVF

ICSI

Egg Donation (recipient)

Lipiodol flushing

Tubal operations

Other

Details of the treatments:

Could you please briefly tell us dates of previous treatements and outcomes

Do you have a single male partner with whom you're trying to conceive?*

Yes

No / I'm single

No - female partner

Choose not to answer

Other

How long have you been living together?

Did your partner

Tick all that apply

Father children

Had his sperm tested

Sperm test details:

Could you briefly give some detail about the the outcome of the test, how long ago was the test done?

Vaginal lubricants?

If trying to conceive naturally, do you use vaginal lubricants?

yes, K-Y®, Durex or similar

yes, canola oil (it has been shown not to harm sperm)

yes, the "sperm friendly" ones from the chemist (like Pre-Seed)

Please note, that supermarket and some pharmacy range lubricants may contain spermicides, which actually aid to prevent conception. Canola oil and some pharmacy range lubricants have been shown to be a safe alternative in some studies.

Do you ovulate

yes (on my own)

yes (with help of medications only)

I don't know for sure

Other

Ovulation day

On what day of your cycle do you ovulate?

Length of menstrual cycle

What's the length in days of your menstrual cycle (including variation)? Example: 24-35 daysThe length of the menstrual cycle is the time between the first day of your menstrual period and the first day of your next menstrual period.

Duration of menstrual bleeding

How many days does your menstrual bleeding last (excluding spotting)?

Are your periods painful?

0 - no pain, 1 - slight pain to 10 - unbearable pain

How heavy is your menstrual bleeding?

1 - light to 5 - heavy

Blood colour and consistency

Please tick all that apply

light red

bright red

dark red

purple

brown

black

some clotting

a lot of clotting

Do you experience premenstrual tension?

no or very light one

sometimes / moderate

often / severe

Do you experience any of these symptoms?

breast tenderness before period

spotting or bleeding between periods

face breaking out before period

premenstrual lower back pain

bowel movements become lose before period

How is your libido?

Libido refers to sex drive or desire for sexual activity. 1 - low to 5 - high.

Did you have any of the following:

cervical biopsy, operation, cauterisation or conization

veneral disease

regular yeast infections

chlamydia infection

chronic vaginal discharge

sores on your genitalia

pelvic inflammatory disease

If any of above questions are current, please detail:

Have you ever been pregnant?

yes, I have child/children

miscarriage(s)

termination(s)

D&C

Children:

Could you please tell about the age of the child(ren) and if he/she was conceived naturally.

Miscarriages, terminations and D&C

If relevant, could you please give a little more detail about the above.

Hormone Laboratory tests?

Did you have hormone laboratory tests performed?

yes

Hormone test results

Could you please outline the results of these tests

Diet

Please tick all that apply

I eat LESS than 3 portions of vegetables a day

I am a vegetarian or eat meat less than once a week

I follow low GI diet

I follow Mediterranean diet

I do not avoid sugars

I drink more than one cup of coffee daily

I do NOT take folic acid (or prenatal supplement)

If you follow any specific diet, please tell us briefly

What is the site of your pain or injury?

Where does it hurt?

Please rate intensity of your pain

Intensity 1 slight pain to 10 pain so severe you can't tolerate

Quality of pain

sharp

stabbing

burning

dull

aching

cramping

throbbing

agonising

nagging

tingling

numbness

weakness

touch sensitive

spasm

shooting

When do you get the pain?

continuously

activity related

night pain

unpredictable

What makes the problem/pain better?

What makes the problem/pain worse?

How long has the pain/ problem been present?

Has the problem/ pain worsened recently?

Yes

Please describe how recently it got worse

How much do these symptoms interfere with your day-to-day functioning?

Is this a

Please tick all that apply

ACC registered injury

Back pain

Neck pain

ACC claim number

How did the injury happen? Please give precise description.

Did you have a fall, or did you perhaps strain yourself while lifting something? Did it result in immediate pain?

Date of injury

MM slash DD slash YYYY

Red flags

Please tick all that apply

Significant trauma

History of cancer

Weight loss

Intravenous drug use

Fever

Steroid use

Pain gets worse when lying down

Please detail any red flags you ticked above

Neurological deficits

numbness

weakness

pins and needles

loss of coordination/balance

a change in bowel and/or bladder habit

other sensory alteration

Previous treatment

Please tick all that apply

physiotherapy

chiropractic/osteopathy

acupuncture

surgery

injections

bracing

other

X-rays or tests done for this issue:

X-rays

MRI

CT scan

Bone scan

Other

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Your condition:

Could you please tell us more about your condition and what you'd like to achieve with our help.

Your health goals:

What is your immediate and long term plan?

Are you and your partner trying to conceive?

yes

no, but in the near future

How long have you and your partner been trying to conceive?

Do you or your partner have a diagnosis related to infertility?

Yes

Diagnosis:

Did your/your partners' diagnosis include any of the following (tick all that apply)

male factor infertility

unexplained infertility

advanced maternal age

PCOS

anovulation

blocked Fallopian tubes

fibroids or polyps

endometriosis

pelvic adhesions

Male infertility diagnosis

Does your male factor infertility diagnosis include any of the following (tick all that apply)

varicoceles

no sperm (azoospermia)

low sperm count (oligospermia)

poor sperm motility (asthenozoospermia)

retrograde ejaculation

immunologic infertility

sperm antibodies

hyperprolactinemia

genital tract infection

low testosterone

chromosome defects (cystic fibrosis, Kallmann's syndrome and Kartagener's syndrome)

undescended testicles

Have you had your sperm tested?

Yes

Sperm test details:

Could you briefly give some detail about the outcome of the test, how long ago was the test done?

Have you had any fertility related blood tests done?

yes

Blood test details:

Could you briefly give some detail about the the outcome of the test, how long ago was the test done?

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Currently you and your partner are trying to conceive

Tick all that apply

naturally

undergoing IUI

your partner is taking Chlomid/Letrozole

IVF/ICSI

other

Has your partner been pregnant with you?

yes, we have child/children

miscarriage(s)

termination(s)

Has your partner conceived following

Tick all that apply

naturally, after the intercourse with you

IUI using your sperm

IVF using your sperm

IVF with ICSI using your sperm

IUI/IVF using donor sperm

other

Have you ever had a pregnancy with another partner?

Yes

When did the last pregnancy happen?

Has the above pregnancy happen following

Tick all that apply

intercourse with you

IUI using your sperm

IVF using your sperm

IVF with ICSI using your sperm

other

History of surgeries?

Tick all that apply

vasectomy

surgical intervention for twisted testes

testes surgically brought to the scrotum

any other surgery to the testes

hernia operation

bladder surgery

other surgery

Please briefly describe what kind of surgery you had and when.

Have you ever had any testicular injuries?

e.g. getting kicked in testes, motorcycle or bike accident that injured your testes.

yes

Have you ever been treated with chemotherapy?

Yes

Are you diagnosed with

Tick all that apply

diabetes

high blood pressure

abnormal cholesterol

STI / sexually transmited infection

What Sexually Transmitted Infection (STI) were diagnosed with?

Have you had a high fever within the last year?

Fever higher than 39 degrees C can severely impair semen quality and even cause temporary loss of sperm.

Yes

Have any of your blood relatives had difficulty to conceive?

Yes

Do you have problems with erections or ejeculation?

Yes

How is your libido?

Libido refers to sex drive or desire for sexual activity. 1 - low to 5 - high.

Have you been recently exposed to large amount of chemicals, pesticides, or radiation?

Yes

Do you frequently use these products

Certain ingredients in these products may impact hormone balance and reproductive health. Your answers help us provide more tailored care.

sunscreen

antibacterial soap

antibacterial toothpaste

antibacterial mouthwash

tanning products

Note: sunscreen and antibacterial products commonly contain hormone-disrupting chemicals, which may have adverse effects on sperm. Research fertility-safe products here.
Journal reference

Have you ever used

Tick all that apply

anabolic steroids

body building drugs

Vaginal lubricants?

If trying to conceive naturally, do you use vaginal lubricants?

yes, K-Y®, Durex or similar

yes, canola oil (it has been shown not to harm sperm)

yes, the "sperm friendly" ones from the chemist (like Pre-Seed)

Diet

Please tick all that apply

I eat LESS than 3 portions of vegetables a day

I eat red meat daily

I have meat less than once a week

I follow low GI diet

I follow Mediterranean diet

I eat potatoes, rice, bread or sweets daily

My diet is rich in Vitamin A

Important lifestyle factors

Please tick all that apply

have hot baths/ pools or sauna

cycle regularly

ever wear briefs (as opposed to loose boxers)

sit long hours at work or home

exposed to high temperatures at work

Don’t take too long over your replies: your immediate is best.

I still enjoy the things I used to enjoy:*

Definitely as much

Not quite so much

Only a little

Hardly at all

I feel tense or 'wound up'*

Most of the time

A lot of the time

From time to time, occasionally

Not at all

I get a sort of frightened feeling as if something awful is about to happen:*

Very definitely and quite badly

Yes, but not too badly

A little, but it doesn't worry me

Not at all

I can laugh and see the funny side of things:*

As much as I always could

Not quite so much now

Definitely not so much now

Not at all

Worrying thoughts go through my mind:*

A great deal of the time

A lot of the time

From time to time, but not too often

Only occasionally

I feel cheerful:*

Not at all

Not often

Sometimes

Most of the time

I can sit at ease and feel relaxed:*

Definitely

Usually

Not often

Not at all

I feel as if I am slowed down:*

Nearly all the time

Very often

Sometimes

Not at all

I get a sort of frightened feeling like 'butterflies' in the stomach:*

Not at all

Occasionally

Quite often

Very often

I have lost interest in my appearance:*

Definitely

I don't take as much care as I should

I may not take quite as much care

I take just as much care as ever

I feel restless as I have to be on the move:*

Very much indeed

Quite a lot

Not very much

Not at all

I look forward with enjoyment to things:*

As much as I ever did

Rather less than I used to

Definitely less than I used to

Hardly at all

I get sudden feelings of panic:*

Very often indeed

Quite often

Not very often

Not at all

I can enjoy a good book or radio or TV program:*

Often

Sometimes

Not often

Very seldom

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Anxiety

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Depression

Used to in past

Few times a day

Smoke tobacco

Recreational drugs

Name

* optional

First Last

* optional

Phone

* optional

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IP address

*Better the information you give us, the better we can help you.

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