New Client Intake — Kopela Health

01

Client information

Tell us how to reach you and who supports your care.

Full name *Date of birth *PronounsPhone numberEmail *OccupationHeightCurrent weightPreferred pharmacy + locationPrimary care clinicianOB/GYNFertility clinic (if applicable)

02

Goals & main concerns

Share what brought you here and what matters most right now.

What are your top 3 health or fertility goals?What concerns, symptoms, diagnoses, or unanswered questions brought you to Kopela Health?How long have you been trying to conceive, preparing to conceive, or working on these health concerns?

03

Medical & health history

This context helps your clinician see the full picture.

04

Reproductive history

Share only what you are comfortable providing today.

Age at first periodTypical cycle length (days)Typical period length (days)Last menstrual periodCycles regular?Ovulation tracked?Usual ovulation dayCurrent contraception

Describe your periodsFlow, clots, spotting, pain, migraines, GI symptoms, missed cycles, etc.

Total pregnanciesLive birthsMiscarriagesEctopic pregnanciesStillbirthsTerminationsPreterm birthsLiving children

Prior pregnancies

Entry 01

YearOutcomeGestational ageComplications / delivery

Prior fertility diagnoses, imaging, procedures, or treatmentsKnown partner fertility testing or concernsInclude semen analysis or sperm DNA fragmentation testing.

05

Current medications

Include prescriptions, over-the-counter products, injections, and topical medicines.

I have no current medications

Medication list

Entry 01

MedicationDoseHow oftenWhy you take itStartedPrescriber

Medications stopped within the last 12 months and why

06

Supplements & vitamins

Include vitamins, herbs, teas, powders, protein products, and wellness products.

Supplement list

Entry 01

Supplement / brandDoseHow oftenWhen takenReason / goal

Supplements recently stopped, not tolerated, or linked to a reaction

07

Nutrition history

There are no right answers—describe what is typical for you.

08

Digestive & metabolic health

These details help connect symptoms, labs, and nutrition.

Digestive symptoms

Usual bowel movement frequency and concernsBlood sugar, insulin resistance, prediabetes, or diabetes historyRecent abnormal metabolic or nutrition-related labsGlucose, A1c, insulin, cholesterol, iron, vitamin D, B12, etc.

09

Lifestyle & daily health

Help us shape a plan that works in your real life.

Average sleep / nightSleep quality (1–10)5Exercise days / weekTypical movement / exerciseStress level (1–10)5Tobacco / nicotine useCannabis / recreational drug useCurrently breastfeeding?

Describe your current exercise or movement routineMajor sources of stress and how you manage themWhat could affect your ability to follow a care plan?Work, caregiving, sleep, travel, finances, culture, or home environment.

10

Recent labs & records

List anything that may help your care team prepare.

11

Anything else

Add anything important that the questions did not capture.

Is there anything important that was not captured above?What would make working together feel successful?

12

Review & confirm

Check your answers before continuing.

Health, medication & nutrition history

Client information

Goals & main concerns

Medical & health history

Reproductive history

Prior pregnancies

Current medications

Medication list

Supplements & vitamins

Supplement list

Nutrition history

Digestive & metabolic health

Lifestyle & daily health

Recent labs & records

Anything else

Review & confirm