Woman's Health Intake Questionnaire

Woman's Health Intake Questionnaire

Thank you for taking the time to complete this form. Your responses will help me understand your needs and tailor our sessions to best support you.

Tell me your name
Email
example@example.com
Phone Number
Please enter a valid phone number.
What is your current height and weight?
How many pounds away are you from feeling confident?
List any diagnosed medical conditions you may have (e.g., thyroid, diabetes, high blood pressure or anything else).
How would you describe your current nutrition? Check all that apply

Whole food, nutrient dense well balanced dietProcessed foodsRestrictiveEmotional/stress eatingOther
Are you currently taking any medications or supplements? If yes, please list below.
Do you have any food allergies or dietary restrictions?
Do you exercise, and if so what type of exercise do you enjoy?
How many hours of sleep do you get on average per night?
Do you have any sleep disturbances? Check all that apply

Night sweatsInsomniaWaking up frequentlyOther
Where are you in your midlife journey>

PerimenopauseMenopauseUnsure
Tell me about what symptoms you are currently experiencing. Check all that apply.

Hot flashesNight sweatsMood swingsAnxiety and/or depressionBrain fog or memory issuesFatigueWeight gainJoint pain or muscle achesSleep disturbancesVaginal dryness or discomfortLow libidoOther
What are your biggest concerns or challenges related to menopause?
What do you hope to achieve through menopause coaching?
Are there specific areas you'd like support with?

NutritionHormone balanceStress managmentExerciseOther
Have you worked with a health coach, nutritionist, or other wellness professional before? If so, what your your experience?
On a scale from 1-10, how committed are you to achieving your health goals?
Is there anything else you'd like me to know about your health, lifestyle, or goals?
Thank you for sharing! I cant wait to start working with you.

You deserve to THRIVE in this stage of life with confidence and vitality.
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