HERS + LUST Tonic Form Name * First Name Last Name Email * Which do you identify as? * Female Other - please book a Tonic Consult, as this product impacts hormones Are you taking any other medications? No Yes - please book a Tonic Consult before placing your order What is your age? * 18-24 25-36 37-56 57-60 Are you currently pregnant or trying to conceive? * No Yes - please book a Tonic Consult before placing your order Are you currently on any form of birth control? * No Yes - please book a Tonic Consult before placing your order Are you taking any other birth control methods? * No Yes - OCP, Intrauterine Device IUD, Contraceptive Implant Other - please explain at the end of this form in the 'Extra information' box Do you have any diagnosed medical conditions? * Endometriosis PCOS Fibroids Infertility Miscarriage Liver conditions Other - please explain at the end of this form in the 'Extra information' box Regarding you Cycle Habits / Symptoms - do you have any noticeable changes with your period? *Tick all that apply. * Prolonged cycle (greater than xx days) Short cycle (less than xx days) Painful periods Irregular periods / spotting between period Absence of period Heavy blood flow / passage of clots Light blood flow Vaginal dryness or pain Painful intercourse Other - please explain at the end of this form in the 'Extra information' box Do you have high blood pressure or low potassium? * No Yes - please book a Tonic Consult before placing your order Do you take regular blood thinners or aspirin? * No Yes - please book a Tonic Consult before placing your order Are you currently taking antidepressants? * No Yes - please book a Tonic Consult before placing your order Do you have a history of liver disease? * No Yes - please book a Tonic Consult before placing your order Have you had any major surgeries in the last 6 months? * No Yes - please book a Tonic Consult before placing your order How much alcohol do you consume per week? * 0-3 standard drinks 4-6 standard drinks 7-11 standard drinks 12+ - please book a Tonic Consult before placing your order Do you have any known allergies to herbal medicine? * No Yes - please book a Tonic Consult before placing your order Are you currently taking warfarin? * No Yes - please book a Tonic Consult before placing your order Extra information Thank you for filling out this form.If you answered ‘YES’ to any of these questions, you will need to book a Tonic Consult before consuming one of our Tonics, please book here. If you have any further questions, please contact us here.
