FERTILITY PATIENT
INTAKE FORM – NATUROPATHY

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133 Catherine Street, Leichhardt NSW 2040
02 9555 8806

Confidentiality assured

Female General Details 

Male General Details 

Female & Male
Reproductive Health
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 Assisted Reproductive History (ART)
Have you undergone any of the following procedures? 
Female Reproductive History
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Have you ever been diagnosed with any of the following?
Have you undergone any of the following investigations?
Menstrual Cycle Details
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Please list the number of days, severity and timing if you suffer from any of the following:
Contraception History
Digestive Health - please select what applies to you
Female to complete
Male to complete
Male Reproductive Health
Have you had any of the following medical investigations?
Have you undergone surgery to your reproductive organs?
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Female to answer 
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Male to answer 
Medical History - self and family
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