Women's Holistic Health Strategies
Helping you harmonize HEALTH, WEALTH, and HORMONES
Full name
First name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
What’s your Instagram?
Are you currently working with a Health Coach to reach your goals? If so, what are you working towards?
If you would like to receive further information or support, please provide your email address (Optional).
How long have you been experiencing perimenopause symptoms?
less than 6 months
6 months to 1 year
1 to 3 years
more than 3 years
Other
How would you rate the severity of your symptoms?
mild
moderate
severe
Which of the following symptoms do you experience? (Select all that apply)
hot flashes
night sweats
mood swings
irregular periods
weight gain
anxiety
perimenopause rage
Other
What are your Primary health concerns related to perimenopause / feminine health
hormonal balance
bone health
heart health
mental health
weight management
Other
Are you currently using any treatments or therapies to manage your symptoms?
yes
no
If yes, what treatments or therapies are you using? (Select all that apply)
Hormone Replacement Therapy (HRT)
natural supplements
lifestyle changes (nourishment / movement)
medications
Other
How often do you exercise
daily
a few times a week
once a week
rarely
Other
How would describe how you nourish your body?
Balanced and nutrious
somewhat balanced
unbalanced
Other
How many hours of sleep do you average per night?
less than 5 hours
5-6 hours
7-8 hours
more than 8 hours
Are you Currently Experiencing any of the following in conjunction to your perimenopause symptoms (check all that apply)
bloating
digestive issues
low energy / fatigue
autoimmune disorders
anxiety
brain fog
fertility issues
trouble sleeping
heavy cramping / periods
Are you experiencing any of the following skin disorders? (check all that apply)
acne
oily skin
dry skin
fine lines
dark spots
dull skin
eczema
rosacea
none of the above
Other
I want to help you find STRATEGIES that work for you. What’s the best way I can share resources with you to address some of these things? Check all that apply.
podcast / book recomendations
send me your masterclasses and virtual class information
send me your product recommendations to help with what I am experiencing.
invite me to local, in person events to learn more
all of the above
Is there anything else you would like to share about your perimenopause experience or health needs?
How soon are you looking to start?
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