The Mamawise Store: Questionnaire for Herbal Extract Dispensing
                                   
Please complete and submit this questionnaire WHEN YOU PLACE YOUR ORDER for any the following liquid herbal extracts:

•  Labour Prep / Labour Ready
•  Naturopath's Birth & Postpartum Herbal Pack
•  Mama's Milk


This questionnaire covers all of these herbal extracts, and is in place to ensure the herbs within the formula/s are suitable for you and your individual situation.

This information remains private and confidential.

You will be contacted via email with a response, or for further clarification within 24 hours (often earlier) of submitting this questionnaire.

Please check your junk/spam folder if you cannot see a response after this time.

If the herbal extracts are deemed unsuitable, or there is any uncertainty of compatibility to your individual situation, they will not be dispensed.

Kristin Beckedahl
Naturopath (B.Nat)
Owner, The Mamawise Store

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Full name: *
Full address: *
Mobile No: *
Your date of birth: *
Email: *
Do you have any allergies, or known food/chemical sensitivities? Please specify. *
Are you currently taking any prescribed medication? Please specify type and dose below. *
Are you currently taking any vitamin/mineral supplements (or prenatal)? Please specify type and dose below. *
Are you currently taking any herbal supplements? Please specify type and dose below. *
Are you currently taking any 'over the counter' medications? e.g laxatives, antacids etc. Please specify. *
Which herbal extract/s are you considering purchasing? *
Required
Have you used any of these Mamawise (previously known as BodyWise BirthWise) products before? *
If currently pregnant, what number pregnancy is this for you? *
If currently pregnant, how many weeks are you now? *
If currently pregnant, how many live babies have you birthed? *
Do you have any current medical concerns within this current pregnancy? *
Required
Have you had any other complications with this current pregnancy that are not listed above? Please specify: *
Where are you planning to give birth? (e.g hospital name) *
Have you smoked during this pregnancy? *
Required
Have you experienced any of the following postnatal issues in the past? *
Required
Has this (or any past) pregnancy been deemed high-risk by your care provider/s? If so, please specify. *
Have you discussed your intention to use herbal medicine during late pregnancy with your maternity care provider? *
Required
If currently breastfeeding, how old is your baby? *
Required
If you currently suspect a low breastmilk supply issue, have you sought support from a lactation consultant? *
Required
If currently breastfeeding, how many breastfeeds is your baby currently having in a 24 hour period? *
Required
Do you have any other information you'd like to add to your booking?
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