return to homepage
Natural Health for Fertility.com

Homeopathic Fertility Program

Please Complete the Following Confidential Homeopathic Fertility Questionnaire

Please understand that the information provided during this Homeopathic Fertility Assessment will be held in strict confidence.

After you click on the submit button, you will be asked to provide the payment
of $95.00 $65.0 US through PayPal.

In an hour or two, you'll receive an e-mail confirming your Homeopathy Fertility Assessment Program Submission. If you don't find the e-mail anywhere, you may have entered a typo in the address. Make sure to let us know because the email you have entered will be used to send your Homeopathic Fertility Program to you.

If you expereince any problems, please contact us.

After submitting your online fertility questionnaire, you will receive the following:

1. Your comprehensive personalized Homeopathic Fertility Program, containing a list of homeopathic remedies and supplements specific for your case.

2. How to use Homeopathic Remedies, when to take them during your menstrual cycle and where to purchase them.

3. Fertility education including fertility charting, tracking your progress, your nutritional and fertility diet changes, and other fertility techniques to help you conceive.

4. Male Partner homeopathic remedies, supplements and tips on increasing sperm count, motility and morphology.

5. Email support fertility coaching for four months.

Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name*
E-mail Address*
Street Address*
City*
State/Prov*
Zip/Postal Code*
Country*
Home Phone*
Age*
1. Enter your age when you had your first period:*
2. When was your last menstrual period (LMP)?*
3. How long is your menstrual Period?*
4. Explain which problems you have with your cycle:*
5. List all the fertility testing results that you have had so far (if any):
6. If you have had fertility treatments and assisted reproduction like IVF, IUI, or other please describe:
7. Please describe the cause of your infertility if you know:
8. Does your partner have any fertility issues, if so please describe:
9. Please describe you overall state of health.*
10. Are you taking any prescription medication? If so, which one and for what?
11. Have you ever been hospitalized? Is so, please describe.
Do you have a history of any of the following infections?
1. Chlamydia.
2. Gonorrhea.
3. Herpes.
4. Venereal Warts.
5. Syphilis.
6. Trichomonas.
Please select all that apply to you.*
1. My period lasts for more than 8 days.
2. My menstrual flow is scant.
3. My menstrual flow is very heavy.
4. I suffer from water retention before my period.
5. I suffer from irritability before my period.
6. I suffer from food cravings before my period.
7. I have never been pregnant before.
8. I have never been pregnant before with my current partner.
9. I have had one miscarriage.
10. I have had more than one miscarriage.
11. My libido is poor.
12. I have been on oral contraceptives.
13. I use lubricants during sex.
14. I have pain during sex.
15. I have vaginal discharges instead of menses.
16. Vaginal discharge that smells like brine or fish.
17. My periods are clotted and look like chopped liver.
18. My periods are bright red.
19. My periods are dark brown.
20. My periods are very painful.
21. My breasts feel swollen before and during my periods.
23. I have vaginal discharge before my period.
24. I bleed after sex.
25. I have had abnormal Pap smear(s).
26. I have one blocked fallopian tube.
27. Both my fallopian tubes are blocked.
28. I have hydrosalpinx.
29. I bleed between periods.
30. I urinate too often.
31. If burns to urinate and I have recurrent urinary tract infections (UTI).
32. Milk or fluid leaks from my breasts.
33. I have acne (face, back, chest).
34. I am often constipated.
35. I pass blood in my stool.
36. I suffer from irritable bowel syndrome (IBS).
37. I suffer from migraines before/during my periods.
38. I suffer from tension headache.
39. I have varicose veins.
40. I have excessive hair growth on my face and/or body.
41. I have/had hair loss.
42. I have a few days of spotting before my periods.
43. I have a few days of brown discharge after my periods.
44. My vaginal discharge is white like cream.
45. My vaginal discharge is green.
46. My vaginal discharge is yellow.
47. I have frequent vaginal itch caused by Candida.
Have you ever had any of the following conditions? Select all that apply to you:
1. Diabetes.
2. Lupus.
3. Arthritis.
4. Asthma.
5. Endometriosis.
6. High Blood Pressure.
7. Recurrent Yeast Infections.
8. Pelvic Inflammatory Disease.
9. Polycystic Ovary Disease (PCOD).
10. Luteinized Unruptured Follicle (LUFS).
11. Hypothyroid.
12. Hyperthyroid.
13. Weight Problems.
14. Abdominal Surgery.
15. Heart Disease.
16. Tuberculosis.
17. Haemorrhoids or piles.
18.Liver Disease.
19.Kidneys problems/disease/stones.
20. Food or Seasonal Allergies/Hay Fever.
21. Chronic Infections.
22. Joint or muscle pain.
23. Chronic Fatigue.
24. Anemia.
25. Gallbladder Disease.
26. Autoimmune Disease.
27. Cancer or Tumours.
28. Scoliosis.
29. Psoriasis.
30. Scoliosis.
31. Skin ulcers.
32. Aneurysm.
33. Anxiety.
34. Bone pains.
35. Compulsive disorders.
36. Alopecia.
37. Abscess.
38. Nephitis.
39. Alcoholism.
40. Headache.
41. Insomnia.
42. Mouth Ulcers.
43. Neuralgia.
44. Styles.
45. Otitis
46. Urethritis.
47. Sinusitis, Rhinitis.
48. Bulimia.
49. Depression.
50.Eczema.
51. Psoriasis.
52. Neuralgia.
53. Rectal fissures.
54. Rheumatism.
55. Scoliosis.
56. Seizures
57. Tinea
58. Warts
Family History: Does anyone in your family have any of the following conditions? Pleae, select those that apply.
1. Birth Defects
2. Tuberculosis
3. Twins, Triplets.
4. Diabetes
5. Kidney Disease
6. High Blood Pressure
7. Ovarian Tumours.
8. Endometriosis.
9. Fibroids.
10. Cancer/Tumurs.
11. Mental Disease.
12. Hepatitis.
13. Polio.
14. Seizures.
15. Stroke.
16. Glaucoma.
17. Emphysema.
18. Ulcers
Do you take any of the following allopathic medications on a regular bases?
1. Antihistamines
2. Decongestants.
3. Aspirin.
4. Anti-inflammatory.
5. Insulin.
6. Antibiotics.
7. Antidepressants.
Toxic Exposure. Please select all that apply.
1. I am been exposed to chemicals.
2. I have been exposed to radiation.
3. I use pesticides or herbicides at home or work.
4. I drink alcohol.
5. I smoke.
6. I have used recreational drugs.
7. I have mercury dental fillings.
8. I have gingivitis.
9. I have had root canal, implants, crowns, etc.
10. I use regular perfumes and antiperspirants.
11. I weak clothes that are dry-cleaned.
12. I wear synthetic materials.
13. I use bug spray in my home.
14. I dye my hair often.
Dietary and life style history. Please select all that apply.
1. I eat red meat, chicken, fish, shellfish, dairy and eggs on regular bases.
2. I am lacto-ovo vegetarian.
3. I am vegan.
4. I always try to consume organic produce whenever possible.
5. I drink sodas, or diet sodas on a regular bases.
6. I rarely eat whole foods rich in fiber.
7. I eat fresh fruits and vegetables every day.
8. I eat at fast-food restaurants more than once a week.
9. I drink coffee every day.
10. I drink less than 8 cups of water a day.
11. I drink tap water.
12. I drink icy cold water or beverages daily.
13. I eat refined carbohydrates on a regular bases.
14. I microwave my food.
15. I sleep less than 8 hours at night.
16. I work night shifts.
17. I exercise more 1-3 times a week.
18. I exercise more than 3 times a week.
19. I practice yoga regularly.
20. I meditate regularly.
21. I have a high stress level at work.
22. I have a high stress level at home.
23. I tend to take shallow breathes and rarely breathe deeply.
24. I have regular chiropractic/osteopathic care.
25. I take vitamins on a regular bases.
26. I suffer from lower back pain.
27. I suffer from joint pain.
28. I suffered physical abuse.
29. I suffered sexual abuse
30. I suffered emotional trauma.
31. I suffered physical trauma.
32. I am often thirsty.
33. I prefer large quantities of water.
34. I prefer warm foods.
35. I crave eggs.
36. I crave meat.
37. I crave carbohydrates.
38. I prefer salty foods.
39. I prefer sweats.
40. Fatty greasy foods aggravate me.
41. I have heart burn or sour burping.
Mental State. Please, select all that apply to you.
1. I am outgoing and I like to be around people.
2. I am shy at first but when I get to know people I am friendly.
3. I do not like to be around people. I prefer to be alone and I am happy this way.
4. When I am in pain or sad I want someone next to me to care for me.
5. When in pain or sad I want to be left alone.
6. I never show how I feel to others.
7. I have experienced loss of loved ones and grief and I have never recovered from that.
8. I cry easily.
9. I never cry and if I have to I will never show myself crying in front of other.
10. I am often irritable and angry for no reason.
11. I am a very clean person and I like order and tidiness.
12. I have many fears.
13. I am easily stressed out and easily influenced by external influences.
14. I dwell on past events in my life.
15. I dwell small things that do not mean anything, but I can't help it.
16. I cannot say no to other. I am a pleaser.
Weather and General Health. Please, select all that apply to you.
1. I am affected by wet, humidity, cold weather.
2. I suffer from dry itchy skin.
3. I feel worse in the mornings.
4. I feel worse after lunch.
5. I feel worse in the evenings.
6. I feel worse at night.
7. I have the flu shot every winter.
8. I have had side effects from mums.
9. I have frequent mood changes.
10. I have many moles and nevi on my skin.
11. I crave chocolate.
12. I love dance and music.
13. I have a fear of infections and I like to keep my hands clean all the time.
14. I suffer from strabismus.
15. My teeth have many cavities.
16. Bone problems.
17. Back pain worse at night.
18. I grind my teeth at night.
19. I suffer from insomnia.
20. I have frequent nightmares/recurrent dreams.
21. I have dreams of falling.
22. I have dreams of flying.
23. I have dreams of being chased.
24. I have dreams of death/killing.
25. I have dreams of fire.
26. I have dreams of rubbers entering my home.
27. I feel better by walking, running and exercise in general.
28. I feel worse by motion and exercise.
29. I am a warm blooded person. I am always hotter than everyone's around me.
30. I am always cold. I have cold hands and feet all the time.
31. I am hot at night and a perspire profusely.
32. I have clammy hand or/and feet.
33. I prefer moving air/open and being outside in fresh air.
I understand that the information provided during this Homeopathic Fertility Assessment will be held in strict confidence. I further understand that the information I receive as a result of this Homeopathic Fertility Assessment is for fertility educational purposes only and should be considered as advice. No information provided is intended to diagnose, treat or cure any disease or condition. Said information is not to be interpreted as a substitution for, or an addition to, medical advice, opinions, or treatment from a qualified physician. I agree to hold www.natural-health-for-fertility.com and its team harmless from any and all claims and from any and all loss, damage, liability or expense, including cost of suit and attorney's fees, resulting from or arising out of my use of said information for the above mentioned purposes. *
I Accept.
Signature (First and Last Name):*
Date (YYYY/MM/DD):*

Please enter the word that you see below.

  



Share This Site

E-mail

Name


Your e-mail is secure!
Online Fertility Program

Fertility Questions
Ask The Expert Now!

The homeopathic fertility program helps couples increase their fertility and prepare for either natural or assisted conception. Getting pregnant has never been easier...

"You are a great fertility coach! I have learned so much about my fertility signs. I now ovulate after months of irregular cycles. I cannot wait to get pregnant."
M. J. Canada

"As I used your three months program to prepare for my third IVF I am pleased to announce that it was successful. I cannot wait to use homeopathy with my baby. I am a firm believer of this healing modality."
Janna, On

"We are pleased to inform you that my husband sperm count is now within normal limits and we are ready to trying to conceive naturally this time. Thank you so much for your advice and assistance."
NY

"Your program is easy to follow and I am now pregnant only after 6 months of trying after years of irregular cycles caused by polycystic ovaries. I have changed my diet and I feel healthy again. Thank you for your support."
London, Ontario


Page copy protected against web site content infringement by Copyscape


The information on this Web Site is not intended to diagnose, treat, cure, or prevent any disease. It is designed for educational purpose only.
Please always consult with a qualified health care professional.

Copyright© 2009-2010 Natural-Health-for-Fertility.com All rights reserved.