Hormone Balance Blueprint — Intake Form
Gain clarity about your symptoms and discover the next steps toward restoring balance and energy.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What are your top 3 health concerns right now?
*
When did these symptoms begin?
*
Which of the following symptoms do you experience regularly?
*
Fatigue or low energy
Mood swings or irritability
Weight gain or difficulty losing weight
Anxiety
Brain fog or memory issues
Insomnia or trouble staying asleep
Low libido
Irregular or heavy periods
Bloating or digestive issues
Hair loss or thinning
Cold hands/feet
Other
Are you currently taking any hormone replacement therapy (including BHRT)?
*
Yes
No
Have you had a hysterectomy or are you postmenopausal?
*
Yes
No
List any current medications or supplements:
List any allergies (including medications):
Do you have any chronic medical conditions (thyroid, diabetes, hypertension, autoimmune, etc.)?
Lifestyle Habits
*
Balanced / clean
Inconsistent
Processed / on-the-go
Restrictive / dieting
How many days per week do you exercise?
*
Please Select
0
1
2
3
4
5
6
7
How would you describe your stress level? (Scale 1–10)
*
1 (Lowest)
1
2
3
4
5
6
7
8
9
10 (Highest)
10
1 is 1 (Lowest), 10 is 10 (Highest)
How many hours of sleep do you typically get?
*
Please Select
<5
5–6
7–8
>8
My Products
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Hormone Balance Blueprint Essential
$329.00
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Hormone Balance Blueprint Comprehensive
$469.00
$
469.00
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Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Next Steps
Once you submit your form, I’ll review your responses and order your hormone test. You’ll receive a confirmation once your order is placed, along with an email that walks you through the next steps — including how to complete your collection and schedule your follow-up consultation.This is the first step toward gaining clarity about your symptoms and understanding what your body needs to feel balanced, energized, and truly well again.If you have any questions in the meantime, please reach out to info@intricatewellness.com — we’re happy to help.
Consent & Agreement
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Client Signature
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Date Signed
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Date
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