Womens Health Consultation Form

1
Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Date Of Birth* This field is required.
Date
Year
Month
Day
6
Please share your GP and any consultant you are currently under.Please note it is advised to discuss any changes you make to your nutrition/lifestyle with your medical team.
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Occupation* This field is required.Is it full time or part time?
8
Height* This field is required.In Meters
9
Weight in Pounds* This field is required.
10
Is your weight:
Stable
Increasing
Decreasing
11
Please list / share your main medical / health history* This field is required.include any surgery you have had, any treatment etc
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12
Please share what your main health goals are & why you are keen to work together.* This field is required.E.g.support hormones, weight management, perimenopausal, tidy up diet, more energy, prepare for pregnancy, missing periods, improve relationship with food etc.
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13
Are your currently trying to conceive or planning to in the next few months?
YESNO
14
What does a current week look like for you in terms of time, commitments, , work schedule, family etc. Please be specific about what your week looks like.
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15
Hip Measurement in CMWidest part of the hips/bum
16
Waist Measurement in CMNarrowest area above the bellow button
17
Chest/ Breast Measurment in CMacross nipple line
18
Thigh Measurements Left & Right in CM
19
Arm Measurement Left & Right in CM
20
If you are not on hormonal contraception. Please list the last 3 period dates & describe what your periods are like.(How many pads/tampons for you use? How many days do you bleed?any spotting? Any clots? Mood & PMS?
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21
Are you currently breastfeeding?
YESNO
22
Please list any medication you are currently taking:* This field is required.
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23
Please list any supplements you are taking. Share the brand and dose. Write "none" if you not taking any.* This field is required.
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24
Do you have a bowl movement every day* This field is required.
YESNO
25
Do you have digestive issues like gas, heartburn, lots of bloating, loose stools, constipation? * This field is required.
YESNO
26
Is there any auto immune issues in your family or diabetes, etc?* This field is required.
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27
Is you skin/ hair an issue?Is your hair thinning, do you suffer from acne, rosacea etc?
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Have you had blood work done with your GP in the last 6 months?* This field is required.If so, please get a copy and send to mAmy 24 hour prior to consultation.
YESNO
29
Please score your stress levels out of 10* This field is required.10 being extremely stressed- 1 being chilled
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2
3
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5
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9
10
30
What time do you go to bed?* This field is required.
31
How many hours of unbroken sleep do you get a night?* This field is required.
32
What time do you wake Monday- Friday?* This field is required.
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What do you do to unwind/ relax / self-care?* This field is required.
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How would you describe your energy levels?* This field is required.
Fine
Hit and miss
I have low energy alot of the time
Other
35
How often do your exercise/get heart rate up?* This field is required.
No exercise
1-2 times a week
3+ times a week
36
Do you have / wear a fitness watch?
YESNO
37
Do you know your step count average* This field is required.
I have no idea
5000- 7000 steps per day
Less than 5000 steps per day
10000 steps per day
38
Do you sit a lot during the day or are you active?* This field is required.
Sit / Sedentary most of the day
On my feet most of the day
39
Have you tracked your food/calories before on My Fitness Pal App?
YESNO
40
In the past, what type of nutrition programmes did you do before if any. * This field is required.weight watchers, slimming world , 1-1 with a different practitioner, etc
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41
In your own words, how do you describe your nutrition/eating habits and what do you feel you are struggling with.* This field is required.
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42
Do you drink 2 litres of water every day?* This field is required.
YESNO
43
What main foods do you dislike?* This field is required.
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44
Please write out 3 of your most common Breakfast, lunches, dinners.* This field is required.
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45
Please list 3-5 snacks & treats you often have.* This field is required.
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Do you eat within 90 minutes of waking everyday?* This field is required.
YESNO
47
Do you skip meals often?* This field is required.
YESNO
48
Do you sit and eat your meals slowly & chew your food well?* This field is required.
Most of the timeIm always rushing
49
How many cups of tea / coffee would you have per day?* This field is required.
None
1-2 cups
3+ cups
Other
50
Do you drink alcohol? If so, how often and what do you drink?* This field is required.
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51
Do you avoid any foods like gluten / diary/ eggs or follow a specific type of diet?* This field is required.
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52
Please confirm that you know if it is your responsibility to check with your GP before you make any changes to diet/ lifestyle and that you will not hold Amy O Mara responsible for any adverse reactions you may sustain while working with her. Amy O Mara is not a doctor and all information is for educational and informational purposes only.* This field is required.
I Confirm / Understand
53
Please confirm that you give Amy permission to hold your personal information on file and give them permission to contact you.* This field is required.
I Confirm and give permission for my details to kept on file and for Amy to contact me.
54
Please Sign Here:* This field is required.By signing you understand that Amy is not a medical professional and therefore it is your responsibility to check with your GP before making any changes to your diet and lifestyle. Amy O Mara will not be held liable for any adverse events that may occur.
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