Chinese Fertility Herbs

FertilityFormulas.com
Women's Health History

Custom Chinese Herbal Fertility Formulas

Fertility Herbalist

Patricia Karnowski M.S.O.M.
P.O. Box 1152

Pinehurst, NC  28370

910-420-2194

Traditional Chinese Medical Diagnosis


To create a custom herbal formula we need to diagnose your condition based on the theories of Traditional Chinese Medicine.

Please complete this health history form to begin the diagnosis process.

Fertility Herbalist Patricia Karnowski M.S.O.M.
will review it personally and call you to discuss whether Chinese herbal formulas would be appropriate for you.
Women's Health Form
Full Name:
Age:


Age of first period:
 painful periods
 pass clots
 do not ovulate
 irregular periods
 scanty periods
 heavy bleeding
 severe PMS
 breast tenderness before period
 easily angered before period
 pimple outbreak before period
 depression before period
 cycle longer than 32 days
 period shorter than 22 days
 back pain when fatigued
 loss stools before period
 constipation
 cold hands and feet
 cold in general
 polycyctic ovarian syndrome
 ovarian cysts
 warmer than other people
 spotting before period
 trouble falling asleep
 trouble staying asleep
 anxiety
 palpitations
 hot flushes
 night sweats
 fibroids
 endometriosis
 taken birth control pills
 luteal phase defect
 hypothyroidism
 excess facial hair
 diabetes
 douche regularly
 use vaginal lubricants
 underweight by 20 %
 over weight by 20%
 constipated
 chronic soft stools
 frequent urination
 no fertile discharge
 chronic discharge
 Hx. of blocked fallopian tubes
 etopic pregnancy
 high FSH
 Hx. of miscarriage
 never been pregnant
 past abortion
 stressful life
How long have you been trying to conceive?:
 tried IVF
result of IVF:
Comments:
Phone number:
best times to call:
time zone:
Herbalist will phone you to go over this form and discuss options.
email address:

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