If you are experiencing more than 3 different Symptoms, please consult further at your initial consultation
Current Medicines and Supplements
Please list any medications/drugs (prescription and non-prescription) - this includes Oral Contraceptive Pill, painkillers, chemotherapies, blood pressure medications, aspirin etc.
Mental and Emotional Stressors
Have you experienced any of the following in the last five years?
Are you currently experiencing any problems with the following? (tick)
1. Tell us about your pregnancy:
2. Tell us about the delivery and birth of this child:
3. Tell us more:
To set clear expectations, improve communications and help you get the best results in the appropriate amount of time, please read each statement and sign below: