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Dr. Annie (Han) Yang 杨 Doctor of Acupuncture & Chinese Medicine DACM 98-199 Kamehameha Hwy Ste F3 Aiea, HI 96701Oahu Acupuncture Clinic 808-582-8660 Central Earth Acupuncture, Cupping & Massage. Traditional Chinese Medicine Clinic

- Dr. Annie (Han) Yang 杨

Doctor of Acupuncture & Chinese Medicine DACM

OAHU ACUPUNCTURE CLINIC

Central Earth Acupuncture, Cupping & Massage

Traditional Chinese Medicine Clinic

Schedule Appointment

Oahu Acupuncture Clinic 808-582-8660 Central Earth Acupuncture, Cupping & Massage. Traditional Chinese Medicine Clinic Dr. Annie (Han) Yang 杨 Doctor of Acupuncture & Chinese Medicine DACM 98-199 Kamehameha Hwy Ste F3 Aiea, HI 96701

98-199 Kamehameha Hwy Ste F3 Aiea, HI 96701

New Patient Special

Facial Acupuncture Package

Insurances Accepted

Located at Pearl Kai Shopping Center

Mon CLOSED

Tues-Fri 9:30am-7:00pm

Sat 9:30am-7:00pm

Sun 9:30am-3:30pm

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OAHU ACUPUNCTURE CLINIC

Central Earth Acupuncture, Cupping & Massage

Traditional Chinese Medicine Clinic

98-199 Kamehameha Hwy Ste F3 Aiea, HI 96701

FERTILITY INTAKE FORM

Health Declaration

Please fill out the following form
in order to participate in our activity.

Full Name

Date of Birth

Date of Last Period

Date

Current Weight

Address/City/State/Zip

Email

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?

No

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?

How frequently do you and your partner have 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?

Was the specimen provided by a partner or donor?

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?

If you have a male partner, has he ever gotten someone else pregnant?

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

Thanks for submitting!

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CONTACT US

Central Earth Acupuncture, Cupping & Massage

Traditional Chinese Medicine Clinic

Our Location:

98-199 Kamehameha Hwy Ste F3 Aiea, HI 96701

Schedule Appointment

INSURANCE PLANS ACCEPTED

If you have any questions please give our office a call 808-582-8660

We also accept cash and major credit cards.

HMSA

KAISER

HWMG/HMAA

TriWest (VA)

New Patient CONTACT FORM

OAHU ACUPUNCTURE CLINIC

Central Earth Acupuncture, Cupping & Massage

Traditional Chinese Medicine Clinic

SCHEDULE APPOINTMENT FORM

Please fill out the following form to Schedule an Appointment

First name

Email

Last name

Phone

1st Visit - New Patient Special ($160 Value) for $100

Includes Consultation & Treatment Plan

1st Visit - FERTILITY TREATMENT - New Patient Special ($200 Value) for $150

Includes Consultation & Treatment Plan

Which Treatments are you interested in? (Click all that Apply) *

Acupuncture Treatment

Cupping Treatment

Fertility Treatment

Guasha

Moxa

Herbs

Tui Na

Massage Therapy

Facial Acupuncture Treatment

NEW PATIENT SPECIAL $100 (value $160) Consultation with Doctor (Includes Acupuncture Treatment & Treatment Plan)

NEW PATIENT SPECIAL - FERTILITY TREATMENT - $150 (value $200) Consultation with Doctor (Includes Acupuncture Treatment & Treatment Plan)

Appointment Date (1st Choice)

Appointment Time (1st Choice)

Appointent Date (2nd Choice)

Appointment Time (2nd Choice)

We will contact you to confirm an appointment Date and Time.

Areas of Concern. Share with us. Mahalo.

Thanks for submitting!

OAHU ACUPUNCTURE CLINIC

Central Earth Acupuncture, Cupping & Massage

98-199 Kamehameha Hwy Ste F3 Aiea, HI 96701

Tel: 808-582-8660

© 2024 Oahu Acupuncture Clinic, Aiea, Honolulu, Oahu.

Dr. Annie Yang

Central Earth Acupuncture, Cupping & Massage. Traditional Chinese Medicine Clinic

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