Fertility Questionnaire | Female | Tonic Natural Health Centre

General Information
Initial Consultation Date*
Date Format: DD slash MM slash YYYY
Your Name*
Title First Last
Your Age*
Your Date of Birth*
Date Format: DD slash MM slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region Postcode Country
Phone (mobile)*
Phone (daytime)*
Phone (after hours)
Email*
Enter Email Confirm Email
Health Fund
Relationship Status*
Spouse's Name
Title First Last
Spouse's Age
Spouse's Date of Birth
Date Format: DD slash MM slash YYYY
Do you have any children?*
- Yes
- No

Please provide detail

Age

Add a new row for each child

Do you have any fertility treatment planned, such as IVF or surgery?*
- Yes
- No
Details of treatment
Please provide details where possible.
Who is your fertility doctor?
Do you give permission to share your treatment plan with your other medical professionals?*
- Yes
- No
How did you hear about our Clinic?

Diet
Do you wash your fruit and vegetables before eating them?*
- Yes
- No
Please provide details, including percentage of organically grown/fed food in your diet

Primary Health Problems/Symptoms

Health Issue	Severity	Year of Onset

Please list any current health problems/symptoms you're experiencing.

Current Medications/Supplements

Medication	Prescribed By	Dosage	Date Commenced

Please list any current pharmaceutical, over the counter, or natural medications/supplements you're taking.

Additional Information
Please provide any additional information you feel is relevant
Please provide any additional reports that you feel are relevant
Drop files here or

General Information

Type	Frequency	Quantity

Treatment	Details	Date