FERTILITY INTAKE FORM | SOUTH BAY ACUPUNCTURE CLINIC Torrance Wellness Center | Dr. Susie Choi D.A.O.M., L.Ac. Doctor of Oriental Medicine Licensed Acupuncturist| Los Angeles Natural Holistic Healing

SOUTH BAY Acupuncture Clinic Torrance Acupuncture Licensed Acupuncurist Torrance 90505 D.A.O.M., L.Ac. Doctor of Acupuncture and Oriental Medicine, a doctoral degree in Traditional Chinese Medicine (TCM)

TORRANCE ACUPUNCTURE CLINIC

Dr. Susie Choi

D.A.O.M., L.Ac.

SOUTH BAY Acupuncture Clinic - Torrance Wellness Center at 3812 Sepulveda Blvd Torrance 90505

Located inside the CitiBank Building

(Sepulveda Blvd / Hawthorne Blvd)

Dr. Susie Choi, Doctor of Acupuncture and Oriental Medicine

310-620-1648

BOOK AN APPOINTMENT

Click to map directions:

3812 Sepulveda Blvd. Ste 370

Torrance, CA 90505

HOURS OF OPERATION

Mon 9:00am-2:30pm

Tues 9:00am-5:30pm

Wed Closed

Thur 9:00am-5:30pm

Fri 9:00am-2:30pm

Sat 9:00am-1:00pm

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FERTILITY INTAKE FORM

Please fill out the following form. Thank you.

Full Name

Date of Birth

Date of Last Period

Current Weight

Address/City/State/Zip

Phone

Preferred Pronouns

Sexual Orientation

Relationship Status

GYNECOLOGICAL HISTORY

How old were you when you had your first period?

How frequently do your periods come?

How long do your periods last?

Do you experience cramping with your periods? If yes, when during your cycles you have pain?

Yes, before

Yes, during

Yes, after

How would you describe the cramps?

Mild

Moderate

Severe

Do you experience any other PMS symptoms?

Lower Back Pain

Mood Swings

Appetite Changes

Sleep Issues

Temperature Fluctuations

Fatigue

Thirst

Others

Do you take pain medication for the cramps? If yes, how much?

How many days before your period do you tend to experience these symptoms?

Have you ever had any of the following infections involving any part of the reproductive tract: (vagina, cervix, uterus, ovaries)

Chlamydia

Trichomonas

Gonorrhea

Herpes

Genital Warts

If yes, what treatment did you receive?

Do you have pain with intercourse?

If yes, does the pain remain in your lower abdomen after intercourse is over?

How frequently do you and your partner have intercourse around ovulation?

What types of contraception have you used in the past?

MEDICATIONS/VITAMINS/SUPPLEMENTS

Please list all over-the-counter medications, vitamins and/or supplements you currently take including any herbal medicines:

FERTILITY HISTORY SUMMARY

Have you ever had a miscarriage? If so, when? And at what week in the pregnancy did you miscarry?

Have you ever had an ectopic pregnancy? If so, when? And how was the ectopic pregnancy treated?

If you were prescribed Clomid or Letrozole, was there a medical reason? In other words, did your doctor know or suspect you were not ovulating naturally?

Have you ever had an IUI? If so, when? What was the result?

Have you ever completed an IVF cycle? If so, when? And what was the result?

FERTILITY EVALUATION

How many months have you been trying to conceive?

How have you been tracking ovulation and/or cervical mucus? If so, for how long?

Have you been using temperature charts? If yes, for how long?

Number of pregnancies?

Number of live births?

Have you ever conceived with a different partner?

Please list any gynecological diagnosis you have received: ie. endometriosis, pelvic infections, ovarian cysts, PCOS, anovulation, etc.

Please list any surgeries or overnight hospital stays:

Blood Test: Follicle Stimulating Hormone (FSH)

Blood Test: Estradiol

Blood Test: Prolactin

Blood Test: Luteinizing Hormone (LH)

Blood Test: Progesterone

Blood Test: Clomid Challenge Test (CCCT)

I declare that the info I’ve provided is accurate & complete

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SOUTH BAY Acupuncture Clinic - Torrance Acupuncture with Dr. Susie Choi - Licensed Acupuncturist 3812 Sepulveda Blvd, Suite 370, Torrance CA 90505

TORRANCE ACUPUNCTURE CLINIC

Dr. Susie Choi, Doctor of Acupuncture and Oriental Medicine

Located inside the CitiBank Building

(Sepulveda Blvd / Hawthorne Blvd)

310-620-1648

HOURS OF OPERATION

Mon 9:00am-2:30pm

Tues 9:00am-5:30pm

Wed Closed

Thur 9:00am-5:30pm

Fri 9:00am-2:30pm

Sat 9:00am-1:00pm

Our Location:

3812 Sepulveda Blvd. Ste 370

Torrance, CA 90505

Torrance Acupuncture is here to help you regain calm, clarity,

and your body's innate healing abilities.

BOOK AN ACUPUNCTURE APPOINTMENT

CONTACT US FORM

Please view our FAQ page.

Fill form below with your questions and we will reach out to you. Thank you

Name (First & Last):

Phone

Which Treatment are you Interested In? *

Acupuncture & Cupping Treatment (Most Popular)

Acupuncture Treatment

Cupping Treatment

Areas of Concern. Thank you.

Thanks for submitting!

Dr. Susie Choi, D.O.A.M., L.Ac

Doctor of Oriental Medicine and Licensed Acupuncturist

South Bay Traditional Chinese Medicine

Los Angeles, Southern California USA

Torrance Acupuncture

Dr. Susie Choi, D.O.A.M., L.Ac. - Doctor of Acupuncture and Oriental Medicine. Licensed Acupuncturist.

South Bay, California

Torrance, Beach Cities, Hermosa Beach, Redondo Beach, Palos Verdes Peninsula, Rolling Hills Estates, Palos Verdes Estates, Palos Verdes, Rancho Palos Verdes, El Segundo, Lawndale, Gardena, Lomita.

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CONTACT US FORM

Please view our FAQ page.

Fill form below with your questions and we will reach out to you. Thank you