Full Name
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First Name
Last Name
Phone Number
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(###)
###
####
Email Address
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Preferred Method of Contact
Phone
Email
Both
Height
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Weight
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Do you have any medical conditions? If yes, please list:
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Are you currently taking any medications or supplements? If yes, please list:
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Do you have any known allergies? If yes, please specify:
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What does your typical diet look like?
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Do you exercise regularly? If yes, what type and how often?
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How many hours of sleep do you typically get each night?
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Do you smoke, drink alcohol, or use recreational drugs? If yes, describe the amount and frequency:
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At what age did you start menstruating?
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Are your periods regular? If no please describe
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Do you experience any symptoms during your cycle (e.g., cramping, heavy bleeding, headaches, migraines)?
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Please list the dates of your last 3 periods:
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Have you ever been pregnant before?
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Yes
No
If yes, were there any complications? Please describe:
Have you or your partner ever been diagnosed with fertility issues?
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Yes
No
If yes, please specify:
Do you or your partner have any children? If yes, do any of your children have any medical conditions or genetic disorders?
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Are you aware of any family medical conditions on either side of your families? Examples include: bleeding disorders, autism, diabetes, genetic syndromes, etc.
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Have you or your partner ever undergone genetic testing? If so, what were the results?
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Is there a history of pregnancy complications in your family (e.g., miscarriages, stillbirths, preterm labor)?
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What are your main goals for this consultation?
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What aspects of preconception wellness are most important to you or feel like a priority right now? (Select all that apply)
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Specify below
Do you have any specific concerns about conceiving or preparing for pregnancy?
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Are there cultural or religious considerations you would like factored into your care?
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Is there anything else you would like to share/discuss:
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