AcuHealthcare Fertility 

Consultation

Please take the time to fill out the information below, to help us understand your circumstance

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Health History
Lifestyle
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Energy LevelLowOkayAverageGoodAwesomeEnergy Level
Stress LevelNot StressedNot often StressedStressed 3-5 times a weekStressed once a dayVery often StressedStress Level
Systems Analysis
Please tick if applicable
Musular Skeletal
Circulatory
Respiratory
Genitourinary
Skin & Hair
Gastrointestinal
Neuropsychological
Senses
Reproductive Health
Menstrual History
Colour of Blood
Do you experience any of the following?
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Pregnancy History
Gynecological Conditions
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Have you ever been diagnosed with;
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Fertility
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Your Signature

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