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        • Aerobic vaginitis (AV)
        • Bacterial vaginosis (BV)
        • Urinary tract infections (UTIs)
        • Vaginal yeast infections and thrush
        • Treat vaginal cracks, cuts and tears
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        Naturopathic Client Intake Form

        All the information your practitioner needs to hit the ground running once you're in the call.

        "*" indicates required fields

        Step 1 of 14

        7%

        1/10: Nuts and bolts

        My practitioner is*
        Name*
        Date of birth*
        I have a*

        2/10: Goals, baby!

        3/10: The nitty gritty symptoms

        I am part of the Killing BV ecosystem*
        I have vaginal/penile symptoms*
        My recent vaginal/penile symptoms include:*
        Odour*
        Discharge*
        The pain is around the:*
        The itch is around the:*
        Vaginal pH*
        During my period, my symptoms*
        I have urinary tract symptoms*
        My urinary tract symptoms include*
        I have had symptoms for*
        Treatments I have tried include:*
        In the past year, a medical doctor has diagnosed me with:*
        I have been tested for sexually transmitted infections*
        I use a condom/barrier when I have sex*
        Across my life, I have a history of*
        Dental and mouth (teeth, gums, jaw)*

        4/10: A little bit of context

        I have used/am using Accutane (isotretinoin) acne drug*
        I use antihistamine medication*
        I use asthma medication*

        5/10: What you're putting in

        This field is hidden when viewing the form
        Describe your diet
        Describe your diet*
        I mostly eat*

        6/10: What you're getting out

        Do you experience digestive issues on a regular basis?*

        7/10: The invisible forces

        8/10: Understanding your hormonal cycles

        What most accurately describes your menstrual status?*
        E.g. how long for, any changes to menstraul patterns/symptoms before/after, type of surgery, etc.
        Hormonal birth control*
        What most accurately describes your menstrual patterns?*
        Usually 20-35 days, but may be longer or shorter. This is NOT your period, but the menstrual cycle includes the days of your period.
        Premenstrual symptoms include:
        I have been diagnosed with or suspected of having:*

        8/10: Crunching the numbers

        Microbiome tests*
        Drop files here or
        Accepted file types: pdf, Max. file size: 12 GB.
          JUNO NOTE: if you have a Juno report, please visit your dashboard (app.juno.bio), click the share symbol, and add info@myvagina.com to share your results with My Vagina.
          Drop files here or
          Max. file size: 12 GB.
            Drop files here or
            Accepted file types: zip, Max. file size: 12 GB, Max. files: 1.
              We can screen your DNA test for a handful of key markers These results are only used for support purposes. Please log into your provider's website and download the raw data file and upload here. Only accepted format is .zip.

              9/10: Almost there!

              Snapshot of your world*

              10/10: Well done! Just two last things...

              IMPORTANT! DO NOT SKIP THIS BIT!*
              Consent to disclaimer*
              Please note this disclaimer is a complex legal document. It essentially means that outside of Australia (where we are bound by Australian law) My Vagina and its practitioners and staff are not legally responsible for what happens to you and you engage with us and follow our recommendations at your own risk.

              In saying this, we are qualified practitioners operating within the legal framework of Australia, and we take this very seriously! We will work hard for you within our capabilities and provide a high level of care.

              MISCELLANEOUS LIMITATION OF LIABILITY
              The client agrees they use My Vagina’s services at their own risk.

              Client releases My Vagina, its officers, employees, directors, subsidiaries, principals, agents, heirs, executors, administrators, successors, assigns, instructors, guides, staff, participants, naturopaths, practitioners and related entities any way as well as the venue where the sessions are being held (if applicable) and any of its owners, executives, agents, or staff (hereinafter “Releasees”) from any and all damages that may result from any claims arising from any agreements, all actions, causes of action, contracts, claims, suits, costs, demands and damages of whatever nature or kind in law or in equity arising from my participation in the consultations.

              Client accepts any and all risks, foreseeable or unforeseeable.

              Client agrees that My Vagina will not be held liable for any damages of any kind resulting or arising from including but not limited to; direct, indirect, incidental, special, negligent, consequential, or exemplary damages happening from the use or misuse of My Vagina’s services or enrolment in the Program.

              My Vagina assumes no responsibility for errors or omissions that may appear in any of the materials.

              INFORMATION PROVIDED
              All your personal and private medical information will be kept confidential under Australian medical laws.

              We will use your information to improve your care using a variety of tools.

              JURISDICTION
              Your use of the My Vagina website and services and any dispute arising out of your use of it is subject to the laws of the Commonwealth of Australia.

              These terms are governed by the laws of the Commonwealth of Australia and subject to the exclusive jurisdiction of the courts operating in Australia.

              My Vagina’s website and resource materials may be accessed throughout Australia and overseas.

              We make no representation that My Vagina’s website complies with the laws (including intellectual property laws) of any country outside Australia.

              If you access My Vagina’s website from outside Australia, you do so at your own risk and are responsible for complying with the laws in the place where you access My Vagina’s website and services.
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              176 High St, Northcote, 3070, Victoria, Australia

              • Popular Topics
                • Aerobic vaginitis (AV)
                • Bacterial vaginosis (BV)
                • Urinary tract infections (UTIs)
                • Vaginal yeast infections and thrush
                • Treat vaginal cracks, cuts and tears
                • Browse My Vagina articles!
              • Shop
              • About Us
              • Support
                • Contact My Vagina
                • Treatment instructions
              • My Programs
                • All Programs
                  • Killing BV Vagina Treatment Program
                  • Killing BV Penis Treatment Program
                  • Perimenopause Survival Kit with Simone Jeffries
              • Ask Aunt Vadge
              • Schedule Consultation
              • Practitioner
                • Apply for Practitioner Access
              • Login
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