Name *

First Name

Last Name

Phone

(###)

###

####

Medical history

PCOS

Endometriosis

IBD

Coeliac disease

Bariatric surgery

Thyroid conditions

Allergies

Miscarriage

MTHFR mutation

History of neural tube defect

Nil

Other (please add details below)

Do you use iodised salt?

Yes

No

Do you have any difficulties swallowing tablets?

Yes

No