1302 Garden Street, Suite F, Santa Barbara 1-805-895-6015

herbal-medicine-santa-barbaraNew Patient Intake Form

Instructions: the purpose of the intake is to be able to look at information regarding all the systems of the body. This gives us clues to imbalances that affect fertility but also show up as symptoms elsewhere in body and mind.

When filling out the systems review please check any boxes that apply to you now or at any previous time in your life.

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Systems Review