INTAKE FORM – NATUROPATHY
133 Catherine Street, Leichhardt NSW 2040
02 9555 8806
Female General Details
Male General Details
Female & Male
Assisted Reproductive History (ART)
Have you undergone any of the following procedures?
Female Reproductive History
Menstrual Cycle Details
Please list the number of days, severity and timing if you suffer from any of the following:
Digestive Health - please select what applies to you
Male Reproductive Health
Have you had any of the following medical investigations?
Have you undergone surgery to your reproductive organs?
Female to answer
Male to answer
Medical History - self and family
Female Diet Diary