※Only authorized medical staﬀ of Acupuncture Clinic for Women Shiryo have access to this interview sheet.

Acupuncture Clinic for Women Shiryointerviewsheet
Date：Year/

First

Last

Name

Name

Address
HeightMonth/

Date/

DOB MM/DD/YY〒TELcmWeightkg

BMI

Please mark the answer with a circle.
１．When did you get married?
Half a year ago / A year ago / A year and a half ago / Two years go
About four years ago/

About ﬁve years ago//

About three years ago

More than ﬁve years ago ( ̲̲̲̲̲ years ago).

２．Questions about menstrual and its symptoms:①How old were you when you started having menstrual periods? Age ̲̲̲②My menstrual periods are…

Regular / Irregular③My usual length of menstrual cycle is ̲̲̲̲ days
④Duration of bleedings ̲̲̲̲̲days⑤First date of last menstrual cycle ̲̲/̲̲̲/̲̲̲(month/day/year)⑥Duration of bleedings in last menstruation ̲̲̲̲̲days⑦My menstrual ﬂow is usually…

Heavy / Normal / Light⑧Do you experience clotting?

Yes / No

⑨Do you have painful periods?

Yes / No

⑩Do you experience any breast tenderness before periods?

Yes / No

３．Questions about vaginal discharge（Please answer only when you have symptoms concerned.）①Do you experience a vaginal discharge in your preovulatory phase?

②If you have experienced diﬀerent color of vaginal discharge before, what color was it?
White yogurt-like / Yellow / Green / Pustule-like / Brownish-red③If you have experienced diﬀerent symptoms of vaginal discharge before, what was it?
White yogurt-like / Yellow / Green / Pustule-like / Brownish-red④If you have experienced diﬀerent symptoms of vaginal discharge before, what was it?
Waterly / Smelling / Painful / Itching

1/4

Yes / No

４．Questions about pregnancy history:①Have you ever used birth control?

( From②How long have you desired your pregnancy? ( For③Have many pregnancy have you had?

yearmonth ) (Foryearsyearsmonths)

months )(Number)

５．Questions about last pregnancy:(When you chose

Number ofpregnancy

1Birth year

Year/
Month/

yesto the question no.5③, please answer the following questions.)

Pregnancy course

2Month/3Month/maternity hospital

M・ F /□ Abortion(Unknownweeks)□Stillbirth(weeks)□ Miscarriage (a positive reaction / a fetal sac / fetal heartb(weeksweeks)

gweeks)□ Type delivery (vaginal delivery / cesarean delivery)

M・ F /□ Abortion(Unknownweeks)□Stillbirth(weeks)□ Miscarriage (a positive reaction / a fetal sac / fetal heartb(□ Ectopic pregnancy(Year/

The name of yourBirth weight□ Type delivery (vaginal delivery / cesarean delivery)□ Ectopic pregnancy(

Year/

Infant sex /weeksweeks)

gweeks)□ Type delivery (vaginal delivery / cesarean delivery)

M・ F /□ Abortion(Unknownweeks)□Stillbirth(weeks)□ Miscarriage (a positive reaction / a fetal sac / fetal heartb(□ Ectopic pregnancy(weeks)

weeksgweeks)

６．Do you work?
No / Yes Working hours (from ̲̲̲̲̲̲̲ to ̲̲̲̲̲̲̲ )( Full-time / Part-time Line of work:̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲ )７．Have you ever experienced any infertility tests? If yes, please ﬁll out the following form.
★ Blood-drawing
Inspection item

Date of implementation Menstrual cycleThe clinic nameComments

Outcome

FSHmIU Year̲̲̲̲̲̲ Month̲̲̲̲̲̲ Day ̲̲̲̲̲̲̲LH

mIU Year̲̲̲̲̲̲ Month̲̲̲̲̲̲ Day ̲̲̲̲̲̲̲estrogen/pg Year̲̲̲̲̲̲ Month̲̲̲̲̲̲ Day ̲̲̲̲̲̲̲

E2pg Year̲̲̲̲̲̲ Month̲̲̲̲̲̲ Day ̲̲̲̲̲̲̲

Progesterone / P4★

mIU Year̲̲̲̲̲̲ Month̲̲̲̲̲̲ Day ̲̲̲̲̲̲̲Prolactin
AMHng/pmol Year̲̲̲̲̲̲ Month̲̲̲̲̲̲ ー

CAI25U Year̲̲̲̲̲̲ Month̲̲̲̲̲̲ ーThyroid function

Normal Abnormal Year̲̲̲̲̲̲ Month̲̲̲̲̲̲ ー

Habitual abortion test Normal Abnormal Year̲̲̲̲̲̲ Month̲̲̲̲̲̲ ー
Antisperm antibodyー・+Year̲̲̲̲̲̲ Month̲̲̲̲̲̲ ーChlamydiaー・+Year̲̲̲̲̲̲ Month̲̲̲̲̲̲ ーー

Laparoscope / Uteroscope

2/4

８．Questions about infertility tests:①Have you ever experienced hysterosalpingography test or hydrotubation te Yes / No
If yes, please explain.
Right: ( Normal / Obstruction / Narrowing / Adhesion / Hydrosalpinx / Everything else)
left: ( Normal / Obstruction / Narrowing / Adhesion / Hydrosalpinx / Everything else)②Has your husband ever experienced sperm testing?

Yes / NoIf yes, please answer the following questions.
Amount of seminal fluid: ̲̲̲̲̲̲̲̲̲̲̲ml Concentration: ̲̲̲̲̲̲̲̲̲̲ ten thousand / ml
Sperm mobility: ̲̲̲̲̲̲̲̲̲ %Spermatozoon malformation rate: ̲̲̲̲̲̲̲̲̲̲̲̲̲ %③Have you ever experienced Huehner test or postcoital test? Yes / No
If yes, please write about the best test results.
(Good / Semi-poor / Poor / others())④Have you ever experienced the timing method?

Yes / NoIf yes, please answer the following questions.
Total experienced number of the timing method in a natural period(number̲̲̲̲)The last date of the timing method: (Year̲̲̲̲ Month̲̲̲̲̲ Day̲̲̲̲̲ )Total experienced number of the timing method in an ovarian stimulation period(number̲̲̲̲)The last date of the timing method: (Year̲̲̲̲ Month̲̲̲̲̲ Day̲̲̲̲̲ )⑤Have you ever experienced AI?

Yes / NoIf yes, please answer the following questions.
Total experienced number of the timing method in a natural period(number̲̲̲̲)The last date of the timing method: (Year̲̲̲̲ Month̲̲̲̲̲ Day̲̲̲̲̲ )Total experienced number of the timing method in an ovarian stimulation period(number̲̲̲̲)The last date of the timing method: (Year̲̲̲̲ Month̲̲̲̲̲ Day̲̲̲̲̲ )⑥Have you ever experienced IVF?

Yes / NoIf yes, please ﬁll out the following chart.

With respect to A Ovarian stimulation, B Fertilization technique and C Implant procedure,please choose the right answer from the following words.(Please fill out to the best of your knowledge.)
A：【A1】Natural period【A２】 Only Clomiphen or Serophen 【A3】 hMG /B：【B1】 Conventional IVF 【B２】Microinsemination(ICSI)C：【C1】 IVF in a natural ovulatory cycle

rFSH (plus Clomiphen)【B3】Rescue ICSI【C２】 Transplantation in a low stimulus period【C3】Transplantation in a period taken hormone adjustment / replacement● Egg-retrieval
DateA

WhetherNumber of Number of Number of Number ofB

Ovarianhcg iseggs

Fertilization

fertilized

stimulation used or not

example Year̲̲̲̲̲̲ Month̲̲̲̲̲

A3

blastocysts implantable

eggs

five12345

3/4

four

blastocysts

threethree

The clinic nametechnique

B1

● Embryo transferDate※Stimulation Endometrium Embryo Tran

C

Number of Fresh embryo

Transfertransplanttechniqueembryoexample Year̲̲̲̲̲̲ Month̲̲̲̲̲

C1one

AssistedSEET※Frozen embryo hatching

HCG levelPregnancy

afterstatus

The clinic nameembryo transfer

fresh / frozenNo / Yes No / Yes

10.3ng

No / Yes

1234
56
7
8
9９．Questions about major disease, operation and condition:①Have you ever experienced any major diseases or operationYes / No
If yes, please explain.
● DiseaseHigh blood pressure（ageLiber ailment（age)Thyroid deﬁciency（age) Diabetes（age)Heart disease（ageKidney disease（age)Asthma（age)Tuberculosis（age)))

Mental illness（ageothers（)）● OperationOvary（age)Uterine ﬁbroid（ageCesarean operation（age) Ectopic pregnancy（age) others（②Do you smoke?
I have smoked ̲̲̲̲̲̲̲̲ cigarette per day since I was ̲̲̲̲̲̲̲̲ years old.

③Do you drink alcohol?
I drink ̲̲̲̲̲̲̲̲ ml of ̲̲̲̲̲̲̲̲̲̲̲ per ̲̲̲̲̲̲̲̲̲̲̲̲.

④Are you presently taking medication?
Yes() / No

１０．Will you tell me how you found our clinic?
①In a magazine （（②Internet（③By a friend（④Others4/4））））)

Appendix（age)