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  • Bodyscapes Fertility Form (Women)

    Please complete all eleven sections of this form (20-25 minutes). If at any time you wish to save and continue filling out this form at a later time, click "Save" (located at the end of each section). A Jotform pop-up box will appear to get your email address. You will be emailed your form to complete at your convenience.
  • 1. General Information

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    Pick a Date

  • 2. Current Fertility



  • 3. Menstrual Cycle

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    Pick a Date
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    Pick a Date
  • 4. Medical History

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    Pick a Date

  • 5. Chinese Medicine Symptom Evaluation

    Please check all symptoms you currently have. Be as specific as possible and don't skip any sections. Even if you don't think it is related to your primary issue, please check it.
  • 6. Stress

  • 7. Sleep

  • 8. Neuromuscular Pain

  • 9. Body Temperature

  • 10. Physical Activity


  • 11. Diet

  • Thank you for completing this form. 

    All information will be kept confidential.

    Please click "Submit" when completed.

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