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Testimonials
Shop
Events
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Get in touch
Name
*
First Name
Last Name
Email
*
Date of birth
*
MM
DD
YYYY
Phone
(###)
###
####
Reason for purchasing fertility guide
Optimising health for future pregnancy
Currently trying to conceive naturally
Currently undergoing assisted reproductive technology (i.e. IVF)
Currently pregnant
Optimising postpartum health
Do you have any health conditions to disclose?
*
Please type no, if appropriate, otherwise please list health conditions.
Did you experience any of the following in childhood)?
Please tick all that apply
Eczema
Night terrors
Asthma
Recurrent UTIs
'Growing pains'
IBS
Many courses of antibiotics
Tonsillitis
Ear infections
Do you take any prescription medication?
*
Please type no, if appropriate, otherwise please list medication.
Do you currently take a prenatal vitamin, fish oil supplement, or probiotic? If so, please list:
Please type no, otherwise please list all prenatal / pregnancy supplements.
Please list any other supplements (herbs, vitamins, minerals, protein powders) that you currently take:
Please list any other supplements of any kind.
What would you like a recommendation for?
*
Pregnancy probiotic
Prenatal multi vitamin
Fish oil
Survey
I rarely get sick
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I get every bug going around
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I was a sickly child but enjoy robust health as an adult
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I often feel run down
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I would be happy to lose a few kilos
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I'm happy with my body shape and composition
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Much of my family have chronic health conditions
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
My family is super healthy and live long lives
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Thank you!