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Datestamp
DD slash MM slash YYYY
Token number
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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 _ _
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Age
Your age is calculated from the date of birth above
Sex at birth
Female
Male
Ethnicity
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
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
No
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
Used to in past
Never
Rarely
Weekly
Daily
Few times a day
Smoke tobacco
Alcohol
Vape
Recreational drugs
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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TCM
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
No
Yes
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
Perspiration
Normal
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
Headaches intensity
Intensity 1 slight pain to 10 pain so severe you can't tolerate
1
2
3
4
5
6
7
8
9
10
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
No
What is the date of your last period? Do you know the reason your cycle stopped?
Fertility
Are you trying to conceive?
Yes
Yes, in the near future
No
How long have you been trying?
Did you or your partner have a diagnosis related to infertility?
Yes
No
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
IVF
ICSI
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 - I'm in a homosexual relationship
Choose not to answer
Male partner
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?
no
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.
Your cycle
Do you ovulate
yes (on my own)
yes (with help of medications only)
no
I don't know for sure
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 days The 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
0
1
2
3
4
5
6
7
8
9
10
How heavy is your menstrual bleeding?
1 - light to 5 - heavy
1
2
3
4
5
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.
1
2
3
4
5
Reproductive health history
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?
no
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
no
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
Pain / injury
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
1
2
3
4
5
6
7
8
9
10
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
No
Please describe how recently it got worse
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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Please tell us about your condition
Your condition:
Could you please tell us about your condition and what you'd like to achieve with our help.
Your health goals:
What is your immediate and long term plan?
Male fertility
Are you and your partner trying to conceive?
yes
no, but in the near future
no
How long have you and your partner been trying to conceive?
Do you or your partner have a diagnosis related to infertility?
Yes
No
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
No
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
no
Blood test details:
Could you briefly give some detail about the the outcome of the test, how long ago was the test done?
Hidden
Male fertility
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?
no
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
No
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
Reproductive health history
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
no
Have you ever been treated with chemotherapy?
Yes
No
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
No
Have any of your blood relatives had difficulty to conceive?
Yes
No
Do you have problems with erections or ejeculation?
Yes
No
How is your libido?
Libido refers to sex drive or desire for sexual activity. 1 - low to 5 - high.
1
2
3
4
5
Lifestyle factors
Have you been recently exposed to large amount of chemicals, pesticides, or radiation?
Yes
No
Do you frequently use
sunscreen
antibacterial soap
antibacterial toothpaste
antibacterial mouthwash
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?
no
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.
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
In the past week, have you been feeling any of the following:
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
Hidden
Anxiety
Hidden
Depression
Personal details
Name
* optional
First
Last
Email
* optional
Phone
* optional
Hidden
IP address
*Better the information you give us, the better we can help you.
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