Wellness Coaching Questionnaire - Haley Holistic Herbalist

Apply to Heal your Womb, Naturally

With Haley Lusk
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Age*
years
I have Post-birth control syndrome or recently stopped the pillI have been diagnosed with EndometriosisI have been diagnosed with Uterine PolypsI experience abnormal menstruation (heavy/painful periods)I have difficulty concentrating/ brain fogI have mood swingsI've had weight gain or difficulty losing weightI sometimes cry over nothingI have been told I have fibroidsI get headaches or migrainesI've had gallbladder problems or had removedMy periods are fewer than 3 daysI have decreased sex driveI struggle with anxiety/depressionI have diarrhea or constipationI have difficulty with memoryI get night sweats or hot flashesI have vaginal dryness or pain with intercourseI have dry skinI have urinary incontinence or leakageI have PMS 7-10 days before periodI have swollen or painful breasts before my periodI feel agitated, weepy or irritated before periodI have had a miscarriage in the 1st trimesterI have had difficulty getting pregnant (6 or more months)I have bloating or gasI have abnormal hair growth on face chest or abdomenI have oily skin or hairI have thinning hair on my headI have acneI have PCOSI have been diagnosed with chronic fatigue or tired throughout the dayI am unable to gain muscle or losing muscle massI have difficulty or unable to orgasmI feel tired in the morning even after sleeping all nightI crave salty or sweet foodI feel at the mercy of stressI have low blood sugar issuesMy energy crashes in the afternoonI have difficulty falling or staying asleepI'm dizzy if I stand up too quicklyI feel overwhelmed by stressI get angry easily or on edgeI have extra weight around midsectionI get shaky if I don't eat oftenI have cold hands/feetI find it difficult to break a sweatI have difficulty healing or prone to injuryI have been told I have Ovarian CystsOther
Whats your birth date?*

MonthDayYear
Date
What is your birth time?*

Hour Minutes

AM/PM Option
What City and State were you born? ( This is for Medical Astrology purposes and will not be shared with anyone)*
Any known food allergies?
Have you done food allergy testing or kept a food journal?
YesNo
BreakfastLunchDinner
YesNo
1-33-5over 5never
1 glass2-3 glassesfull gallon alwayswhat's water?
What is your current water source? *
TeaJuiceSodaCoffee/Energy Drinks
Right when I wake upMid-dayAfter workAll day
12345678910
Why?*
Accountability, eating well and doing the things that keep me feeling my bestJust starting to balance my hormones!I've hit a plateau & I need to change thatI'm trying to conceive
Please list all current supplements, herbs and medications you are taking.*
YesNo
Less than $100$100 -$300$300 - $500$300-$500$500 - $1000$1000 - $3000
CallTextEmail
I am so excited that you decided to reach out to me to help you with your wellness goals! I can't wait to work with you! I'll reach out within 24 hours!
Should be Empty:

Apply to Heal your Womb, Naturally