The BodyWise BirthWise Store: Questionnaire - Liquid Herbal Dispensing
                                   
Please complete and submit this questionnaire BEFORE placing your order.

This questionnaire must be completed in order to purchase one or more of the liquid herbal extracts.

This questionnaire covers all of the liquid herbal extracts available.

This questionnaire 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 1-4 hours 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 BodyWise BirthWise Store

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Full name: *
Full address: *
Mobile No: *
Email: *
Your date of birth: *
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? 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 liquid herbal extract were you considering purchasing? *
Obbligatorio
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? *
Obbligatorio
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)
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Have you smoked during this pregnancy? *
Obbligatorio
Have you experienced any of the following postnatal issues in the past? *
Obbligatorio
Has this (or any past) pregnancy been deemed high-risk by your care provider/s? If so, please specify.
Cancella selezione
Have you discussed with your maternity care provider your intention to use herbal medicine during late pregnancy? *
Obbligatorio
If currently breastfeeding, how old is your baby? *
Obbligatorio
If you currently suspect a low breastmilk supply issue, have you sought support from a lactation consultant? *
Obbligatorio
If you suspect you have a low breastmilk supply, is there anything that you have contributed this to? *
Obbligatorio
If currently breastfeeding, how many breastfeeds is your baby currently having in a 24 hour period? *
Obbligatorio
Do you have any other information you'd like to add to your booking?
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