“All the Tea” FAM Intake Form Date * MM DD YYYY Name (what would like me to call you?) * Email * What are your preferred pronouns? Location * Phone (###) ### #### Date of Birth * Age * Height * Weight * Are you content with your body as it is? Very much so For the most part I'm neutral about it Not so much Not at all other Occupation Heritage Blood Type Where/From whom did you hear about me? * GENERAL Please answer the following questions about yourself! What are your goals for our work together? * What is your history with Cycle Tracking? * Are you in a supportive relationship? Is there anything you'd like to share with me about your sexual orientation that feels relevant? Are you currently cycling? * In other words, do you have periods? Yes No CHARTING If you currently chart your cycle, please answer the following questions Where/From whom did you learn to chart your cycle? What does your temping practice look like? (Typical time of temp, temping daily? Before rising?) What does your cervical fluid practice look like? (How often are you checking? How do you check? How do you record?) Do you track other signs of fertility? If so, which? How do you keep your information- paper chart? App? Do you have any questions about your charting practice? Perhaps, anything you'd like to be more clear? BIRTH CONTROL / CONTRACEPTION Please share a bit about your history with contraception What methods of birth control have you used in the past? Please share specific history of hormonal contraceptive use; types, years used, side effect, etc... List the date you last took a hormonal contraceptive (month/year) What form(s) are you using currently? Do you have intentions to become pregnant either now or later? On a scale of 1-10, how would you rate your 'pregnancy intention'. 1 - I want to be pregnant NOW. The sooner the better 10 - NEVER want to get pregnant. I will terminate a pregnancy if it happens 1 - I want to be pregnant NOW. 2 3 4 5 6 7 8 9 10 - NEVER want to get pregnant . CYCLES (cycle= entire cycle menses/ovulation/day one to day one) (menses= bleeding time) Please answer if you are currently cycling, or if not, you may answer in regards to past cycles you've experienced When did you last cycle/period begin (name the date as best you can) How regular are/were your cycles? (check one) Very regular Variable (list range on comments below) Definitely Irregular (list details on comments below) I only bleed_____x/year (list comments below) Comments: Are you already aware of your more fertile times? If currently tracking... how many days of cervical fluid do you normally see each cycle? don't know 1-2 3-5 6-10 If currently tracking, please list the types of CF you regularly see. Be explicit (example: lots of stretchy, goopy stuff, a little bit of gummy and some yellowish creamy) MENSES Please share about your bleeding time Heavy / Medium / Light flow? Heavy Medium Light Average length of bleeding time Describe the consistency of your blood flow thin thick stringy goopy clotty What color would you say your blood is? bright red dark red pink brown What pattern does your blood flow in? light, heavy, medium, light, spotting heavy, medium, light, spotting heavy, light... medium, light... light only What does a 'heavy' day of bleeding look like to you? I fill 2 or more menstrual cups in a day I go through a tampon or pad every few hours I fill one menstrual cup in a day I use a few pads/tampons in a day I may fill one pad or tampon in a day I only need panty-liners on a heavy day Are your periods painful? How would you rate the pain on a scale of 1-10? 1 Not painful 2 3 4 5 6 7 8 9 10 Very painful Cycle Health and History What specific questions/comments or concerns do you have about your cycle? At what age did you begin bleeding? If you have experienced peri-menopausal symptoms or transitioned through menopause, at what age did that happen? Are you aware of what age your mother was when she experienced menopause? Do you have a history of reproductive issues in your maternal lineage? If so, please describe. History of recurrent yeast infections, BV or other flora imbalances? History of STI’s or other infections? Do you use a lubrication during sexual relations and if so, what type? Any history of abnormal paps? Have you ever had any cervical procedures? (colposcopy, LEEP, etc...) Other cyclical discomforts (such as PMS/headaches/etc) Which of these symptoms are most challenging? Pregnancy Achievement & Pre- Pregnancy Achievement Answer if this section apply to you Pregnancies; Dates and Outcomes (includes live births, pregnancy losses and terminations) If you have had a pregnancy loss or termination, do you feel resolved about it? Yes No Maybe Comments: Any history of challenges with pregnancy achievement ? Are you currently breastfeeding? Do you have any known conditions regarding your fertility? Have you had any fertility testing done? If so, what were the results? Has your partner undergone fertility testing. If so, what were the results? How long have you been ‘trying’ to conceive and how actively? GENERAL HEALTH Please list any other REPRODUCTIVE health issues, past or present. Please list all other health issues or conditions (even if you think they wouldn’t be relevant) . Are you currently taking medications for these conditions? Please list. Please list other 'symptoms' that you experience that are not associated with a diagnosed condition What would you say is your weakest system constitutionally? Digestive system, respiratory, skeletal Were you breastfed as a baby? For how long? How would you describe your digestion? How often do you have a bowel movement and how would you describe it? (ex: hard pebble like, unformed...) How would you describe your dietary habits? What type of diet do you eat? (e.g., Omnivore,Vegan, Keto, WAPF, Paleo, etc.) Are there foods you avoid? If so, what are they and why do you avoid them? How much water do you consume each day on average and where do you source your water? (filter, tap, spring, well...) Do you consume caffeine and if so, in what form and how much/often? Do you use recreational or prescription drugs? If so, what type and how often? What supplements do you regularly take? What does a typical breakfast look like for you: What does a typical lunch look like for you? What does a typical dinner look like for you? What about snacks and drinks? Do you eat organic foods? If so, what percentage? Do you have any significant chemical exposures due to work or living conditions? (example- living near orchards, house-cleaning with conventional products, etc...) Do you have any known allergies (food or otherwise)? Do you have a history of extensive dental work? Please explain. Were you vaccinated as a child and have you received boosters as an adult? Did this include the Gardisil vaccine? No Yes vaccinated as a child and as an adult Vaccinated only as a child Received the Gardisil HPV vaccine How many hours of sleep do you get each night on average? How well do you sleep? Any troubles? Do you have any lighting in your room while sleeping? (alarm clock, street lights, etc...) How much screen time and during what hours of day? What is your stress level? What stress relief tools do you utilize? How strong would you consider your libido (sex drive) to be? Above Average Average Below Average Are you happy with your current libido? Would you like to discuss it? Do you have meaningful relationships/connections in your life? Yes No Some- but could use more Would you like to discuss the above question? Yes please No Need Maybe, ask Do you feel you have the resources to receive the healthcare you desire? Please share what types and what frequency that you exercise: Have you had any significant traumas you’d like to mention? Do you receive regular bodywork or preventative care? Are you open to making dietary/lifestyle changes to shift your reproductive health? Consent Agreement I understand that attending this consult/class does not guarantee that I or my partner will have the desired outcome we are seeking. I further understand that if I have any questions or problems that I should contact my instructor or other health care practitioner. I understand that using this method for contraceptive purposes, even when used correctly, can fail. I am aware that recent studies performed in Germany using a very similar method (Sensiplan) have been shown to be 99.4 and 99.6% effective with "perfect use" and 98.4% with typical use. I understand that these rates are highly dependent on the learning model, the teacher, the student's comprehension and many other factors. This particular study utilized a very controlled population so may indeed have a falsely high 'typical use' rate compared to other cultural settings. I claim full responsibility for my use of this method and the information received in this consult, as well as for my own health. I further understand that any information disseminated in this class is for the purpose of education and is not intended to diagnose, cure or treat disease. I thus release all liability of my teacher. Consent Signature * Date MM DD YYYY Partner's Consent Signature (if present) Use of Material for Educational Purposes (OPTIONAL) I grant permission for Saphira "Safi" Contreras, FAE, at 'Soul Center', to use my charts and client information to further FA education in the world. She may share my charts (anonymously) with future students while teaching. My privacy will ALWAYS be respected and strict confidentiality will be upheld. Material Usage Signature Thank you for the time. Looking forward to working with you .
