Women's Health & Fertility Questionnaire

This questionnaire will provide helpful information for your Hart & Sol Naturopathic Doctor in creating your customized treatment plan. It may not be required for all patients. If you are unsure if you have any of the symptoms listed below, leave the checkbox blank. You will be required to note how your tongue appears. VERY IMPORTANT: stick your tongue out while looking in a mirror UPON RISING before drinking, eating, or brushing your teeth, and note the appearance of your tongue. Colour? Thick? Thin? Coating? Cracks? Teeth marks?

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