Private fertility intake portal

Fertility health history forms for focused, prepared care.

Complete the relevant form before your appointment so your practitioner can review your history, fertility goals, medications, lab results, cycle details, lifestyle context, and consent acknowledgements in advance.

Responses are sent to [email protected] Complete ideally 24 hours before your appointment

Confidential by design

Questions are grouped into calm chapters so clients can complete detailed health histories with less overwhelm.

Email submission

Each submitted form is sent to [email protected]. The first submission may require a one-time FormSubmit activation email before messages start arriving.

Ready for consultation

Consent, cancellation, lab-copy acknowledgement, and signature fields are included at the end of each form.

Female Fertility & Gynaecological Health Intake Form

A private health-history form to complete before your appointment.

Please answer as much as you feel comfortable sharing. Detailed answers help your practitioner tailor treatment safely and effectively.
01Client profile

Contact details

Do you consent to B.Nourishd Wellness contacting your GP, gynaecologist, or fertility doctor about your care?
02Personal questions

Personal fertility history

Are you currently pregnant?
Have you been diagnosed with NK cells?
Have you been diagnosed coeliac?
Do you have an MTHFR gene mutation?
Have you been diagnosed with a thyroid issue?
03Health history

Gynaecological history

Please check if you have had any of the following
Do you have any other diagnosed gynaecological issues?
Do you use vaginal lubricants?
04Health history

Menses and cycle health

Do you spot or stain before your period?
Cramping and pain with your period
Is there clotting or clumps?
What menstrual products do you use?
What colour is the blood?
Do you get PMS symptoms?
Low back pain before your period?
Breast tenderness before period or at ovulation?
Do bowel movements change with your cycle?
05Health history

Ovulation

Has your cycle changed recently?
Do you track your temperature / BBT?
Do you notice fertile cervical mucus at ovulation?
Do you have increased libido at ovulation?
06Health history

Fertility treatment history

Have you had fertility treatments?
Have you been given a formal diagnosis relating to fertility?
Have you taken medication to help you ovulate?
Have you had any tubal operations, tube flush, or patency test?
Have you had any eggs collected in an IVF cycle?
Have you used ICSI or HA-ICSI?
Have you had genetic testing on embryos, such as PGD or screening?
Have you had hormone labs, ultrasounds, scopes, sperm tests, or investigations in the last 12 months?
07Health history

Contraception

Have you taken oral contraceptives?
Have you taken Depo Provera?
Have you had an IUD?
08Health history

Medications and supplements

09Health history

Partner or donor details

Do you have a partner with whom you are trying to conceive?
Is your partner supportive of your wish to conceive?
Has your partner or donor had a fertility workup / semen analysis?
Has your partner or donor had children previously?
Does your partner/donor have any of the following?
Would your partner/donor be open to receiving fertility support with
Is your partner willing to undergo a semen analysis to check for fertility issues?
10Health history

Additional symptoms

Please tick any symptoms experienced in the last six months. These questions help your practitioner tailor assessment and treatment.

Kidney Yin/Jing Deficiency
Kidney Yang Deficiency
Spleen Qi Deficiency
Blood Deficiency
Blood Stasis
Liver Qi Stagnation
Heart Deficiency
Excess Heat
Dampness
Lung
11Health history

Consent and signature

Chinese medicine treatment risks, cancellation policy, and informed consent

Acupuncture, cupping, moxibustion, electro-acupuncture, herbal medicine, heat therapy, and nutritional support may involve risks including pain, bruising, blistering, infection, burns, sleepiness after treatment, and possible herb, supplement, or medication interactions. Please notify your practitioner if you have an infectious disease, haemophilia, heart condition, pacemaker, are taking blood-thinning medication, are pregnant, have epilepsy, have suffered seizures, have immune concerns, bruise easily, or have sensitive skin.

B.Nourishd Wellness requires at least 24 hours’ notice for cancellations or rescheduling. If you cancel with less than 24 hours’ notice or miss your appointment, you may be charged 100% of the scheduled service fee.

I understand the risks associated with Chinese medicine and will ask my doctor or practitioner if I have concerns. required
I understand I may be charged 100% of the appointment fee if I cancel with less than 24 hours’ notice. required
I confirm I have read and understood the informed consent statement and give permission for treatment to proceed. required
I understand my medical records and lab reports will be kept secure and confidential unless I provide written consent for release. required
I am able to email or bring copies of blood and lab tests performed within the previous 12 months, if relevant.
First-time email confirmation: if this is the first submission from this website, FormSubmit may send an activation email to [email protected] before releasing stored submissions. Please check Inbox, Spam, Junk, Promotions, and search for “FormSubmit” or “activate”.

Male Fertility / Urogenital Health Intake Form

A structured form for fertility, urogenital, lifestyle, and lab history.

Please complete this form at least 24 hours before your appointment when possible.
01Client profile

Contact details

02Health history

Fertility background

Have you been given a diagnosis related to fertility?
Have you tried any fertility treatments?
03Health history

Medication, lifestyle, and allergies

Do you have any drug reactions or allergies?
Are you currently taking any prescription medications?
Are you currently taking any supplements?
Do you use marijuana?
04Health history

Urogenital history

Do you have any history of varicocele?
Have you ever had undescended testes?
Have you had any urogenital surgeries?
Have you had trouble maintaining an erection?
If so, did the problem exist with self stimulation?
Have you ever experienced premature ejaculation?
Do you experience a morning erection?
Do you experience nocturnal emissions regularly?
Have you experienced any issues with low libido?
Have you experienced abnormal discharge from your penis?
Do you get night sweats?
Do you get lower back pain?
Do you get reflux?
Are you tired or fatigued throughout the day?
Do you use asthma medication?
Do you suffer from mood swings or depression?
Have you been exposed to any environmental toxins?
05Health history

Lab testing

If you have received lab tests, please bring or email a copy for your appointment.

Have you had a sperm analysis?
Are you willing to complete a semen analysis to check for fertility issues?
06Health history

Fertility history

Have you had children previously?
Do you bicycle regularly?
Do you use a hot tub, sauna, or hot bath regularly?
Medical conditions: please select any/all that apply
07Health history

Additional symptoms

Please tick any symptoms experienced in the last six months.

Kidney Yin/Jing Deficiency
Kidney Yang Deficiency
Spleen Qi Deficiency
Blood Deficiency
Blood Stasis
Liver Qi Stagnation
Heart Deficiency
Excess Heat
Dampness
Lung
08Health history

Consent and signature

Chinese medicine treatment risks, cancellation policy, and informed consent

Acupuncture, cupping, moxibustion, electro-acupuncture, herbal medicine, heat therapy, and nutritional support may involve risks including pain, bruising, blistering, infection, burns, sleepiness after treatment, and possible herb, supplement, or medication interactions. Please notify your practitioner if you have an infectious disease, haemophilia, heart condition, pacemaker, are taking blood-thinning medication, are pregnant, have epilepsy, have suffered seizures, have immune concerns, bruise easily, or have sensitive skin.

B.Nourishd Wellness requires at least 24 hours’ notice for cancellations or rescheduling. If you cancel with less than 24 hours’ notice or miss your appointment, you may be charged 100% of the scheduled service fee.

I understand the risks associated with Chinese medicine and will ask my doctor or practitioner if I have concerns. required
I understand I may be charged 100% of the appointment fee if I cancel with less than 24 hours’ notice. required
I confirm I have read and understood the informed consent statement and give permission for treatment to proceed. required
I understand my medical records and lab reports will be kept secure and confidential unless I provide written consent for release. required
I am able to email or bring copies of blood and lab tests performed within the previous 12 months, if relevant.
I acknowledge that I may be required to obtain semen analysis, blood tests, or other investigations in the first few weeks of treatment.
First-time email confirmation: if this is the first submission from this website, FormSubmit may send an activation email to [email protected] before releasing stored submissions. Please check Inbox, Spam, Junk, Promotions, and search for “FormSubmit” or “activate”.