Sage Fertility Assessment Quiz

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Intake Form Backup (Scale Fields, 03/02/21)

Personal Information

Have you been treated by acupuncture before?
I have been evaluated by a physician for the condition(s) being treated within the past 12 months *
May we share information with your other healthcare providers? *

General Health History

Consider which of the following symptoms you experience on a scale of 1-10 (1 being very mild and 10 being severe). Then rate those that are above 4 and leave the others blank.
List all of the medications, supplements, vitamins, and herbs that you have taken in the past 6 months including the reason taken and dose


Describe your average daily diet

Family History

In addition to acupuncture I am interested in receiving

Nutritional Advice
Supplement recommendations
Herbal recommendations (If Yes, I acknowledge that I am not currently using medication to try to conceive).

Female Reproductive History

List any of the following that apply to you:
Polycystic ovaries
Diminishes ovarian reserve
Blocked/damaged fallopian tubes
Sexually Transmitted Disease
Unexplained Infertility
Are you charting your BBT temperatures?
List the date and result for any of the following lab tests that you have received:

If applicable, please include the number of embryos frozen, genetically tested, and transferred under outcomes.
Are your cycles regular:
Do you have clots (tissue in menstrual flow)? If Yes what size (ex: almond, egg yolk)

Male Reproductive History

Medical History
Please list any of the following conditions that you have had:
Undescended testicles
Injury to testicles
Hernia Repair
Bladder or prostate issues
Urinary tract infection
Sexually transmitted disease
Problems achieving erection
Problems with sex drive
Abnormal sexual development
Fever within the last 3 months
Family history of fertility problems
Early problems (before 12 yrs old)
Late puberty
History of mumps
Neurological problems
Hormonal problems (ex: diabetes, thyroid)
Semen analysis results

Informed Consent

do hereby request and give permission to receive treatment from Sage Acupuncture LLC, and any affiliated Licensed Acupuncturist. Traditional Chinese Medical treatments include various modalities including but not limited to acupuncture, cupping, gua sha, herbal, and dietary supplements. I understand that I have the right to inquire about and refuse any part of the treatment.

I understand and am informed that, as in allopathic medicine, in the practice of Traditional Chinese Medicine there are some risks of treatment. I understand that although these risks are unlikely to occur, they are possible. These risks include but are not limited to: bleeding, bruising, nerve damage, punctured organs, aggravation of symptoms, the appearance of new symptoms, fainting, and fatigue. I do not expect the practitioner to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioner to exercise such judgment to be in my best interest based on the known facts at the time. Although I am aware that acupuncture and the other procedures used in Traditional Chinese Medicine have helped millions of people, I understand that no guarantee of cure or improvement in my condition is given or implied.

Policies & Procedures

Appointment Reminders and Follow Up Communication

We may use or disclose your health information to provide you with appointment reminders and follow up communication via phone, voicemail, email or letter.

Privacy Practices
I have reviewed Sage Acupuncture LLC’s notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document upon request.

Payment is due at the time of service. We accept cash, checks, and most major credit cards.
Your appointment time is reserved specifically for you. In the event of a missed appointment or an appointment canceled for any reason with less than 24 business hours notice you will be charged a fee.
A $30 fee will be charged for returned checks.
We reserve the right to change our fee scale without notice.

Media Release
Any photographs, audio or video recordings of myself or my family that I participate in or submit to Sage Acupuncture LLC, may be used for any purpose without compensation in perpetuity.

I have completed this form to the best of my knowledge. I have read and understood the Informed Consent and Privacies & Procedures information. By signing below I agree to a course of treatment in Traditional Chinese Medicine and intend this consent form to cover the entire course of treatment for my present condition as well as any future condition(s) for which I seek treatment with this practice.

Finish and Submit

I have completed this form to the best of my knowledge. I have read and understand the informed consent, privacy, and procedures information. By entering my initials below I agree to a course of treatment in Oriental Medicine and intend this consent form to cover the entire course of treatment for my present condition as well as any future condition(s) for which I seek treatment with this practice.
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