Thrive Through Menopause - Woman's Health Intake Questionnaire

Thrive Through Menopause 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.

Name
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.
Age
Height:____________ Current Weight:____________
Are you comfortable with your current weight?

YesNoIf no, how many pounds are you away from feeling confident? ___________
Date of last menstrual cycle
List any diagnosed medical conditions you may have (e.g., thyroid condition, diabetes, high blood pressure, osteoporosis/osteopenia, stroke, cancer, or anything else).
How would you describe your current nutrition? Check all that apply

Emotional/stress eatingRestrictive calorie dietFast foodWell balanced diet (whole food, nutrient dense)Other:________________________
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?

PerimenopauseMenopausePostmenopause
What symptoms you are currently experiencing? Check all that apply.

Hot flashesNight sweatsMood swingsAnxiety and/or depressionBrain fog or memory issuesFatigueWeight gainBloatingJoint pain or muscle achesMuscle weaknessSleep disturbancesVaginal dryness or discomfortPain with sexual activityLow libidoOther____________________________
Urogenital Health History. Do you experience any of the following (check all that apply)

Urinary UrgencyUrinary frequencyUrinary Incontinence (leakage)Recurrent urinary track infections
How would you rate your stress levels?

LowModerateHigh
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?

NutritionWeight LossHormone balanceExercise/strengtheningSleepStress ManagementUrinary Incontinence (leakage)Other:______________________________________
Are you currently undergoing any treatment for menopause (Hormone Replacement Therapy (HRT) or Supplements)?
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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Thrive Through Menopause Woman's Health Intake Questionnaire