Womb Wellness Intake Form
Personal Info
Name
First Name
Last Name
Age
Height
Weight
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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What symptoms or womb-related challenges are you currently facing?
Fibroids
PCOS
Painful periods
Endometriosis
Infertility
Menopause
Heavy bleeding
Irregular cycles
PMS
PID
STI
UTI
Hysterectomy
Pain
Herpes (please inform practitioner)
Other
Are you currently pregnant?
Yes
NO
Are you currently on birth control?
Yes
No
If so, what?
How long?
Are you currently on any medications?
Yes
No
If so, name(s) and dosages
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Have you had any surgical procedures?
Yes
No
If so, please provide details
Do currently have a menstrual cycle
Yes
No
Is your cycle regular?
Yes
No
Do you experience cramps, clots, or heavy bleeding?
Headaches
Yes
No
Which brand of sanitary pads or tampons do you use?
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Number of pregnancies:
Live births:
C-sections:
Losses (miscarraige, stillbirth, abortion):
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Are you currently experiencing any of the following?
Stress
Anxiety
Depression
Grief/Sadness
Insomnia
Insomnia
Hypertension
High Blood Pressure
Confused
Unfocused
Compulsive
Lack of Energy
Consistenly Frustrated/Annoyed
Memory Trouble
Anger
Indecisive
Hyperactive
Feeling disconnected from your body
History of trauma (optional to share):__________________
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Sexually active
Yes
No
Last date of sexual activity
Do you enjoy it?
Yes
No
Is it painful?
Yes
No
Have you experienced orgasm?
Yes
No
Rape
Yes
No
Molestation
Yes
No
Domestic Abuse
Yes
No
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Are you currently in a relationship?
Yes
No
If so, how long?
Is there any abuse (physical, mental, emotional, financial)?
Yes
No
Are you happy?
Yes
No
What are you seeking from this coaching experience
Relief from symptoms
Emotional healing
Fertility support
Spiritual connection to womb
Postpartum care
General wellness
Submit
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