Menopause form

Menopause & Strength Rebuild Assessment

This is a safe space. You are not broken, behind, or alone. Your body is changing — and you're learning to change with it.Answer what you can — no perfection needed.We’ll help you find the right support. No one will see this but me.
Today's date

MonthDayYear
Date
Name

I am Coach Tracy, Glamm or Coach T.Last Name
pronouns
I am She /her
Best contact email
example@example.com
Your age
Which one of these would make you most comfy in working with/talking to me.
Which best describes you?
Symptoms you're experiencing: (check all that apply)

Other
Tell me about "other" if you chose it.
Have you had any of these medical procedures/concerns?
Feel free to share if you are comfy.
Are you on medication?
You do not have to tell me how much or what. Just general info. I take vitamins, biotin, elderberry, and anti depressant.
Are you currently taking HRT/replacement therapy?
Feel free to share if you feel comfy.
I do not sell or recommend anything in my programs. I'm learning how to best help.
FITNESS BASELINE
What best describes your current exercise routine?
Movement PreferencesMovement preferences:
Any injuries or limitations I should know of?
Nutrition baseline
How do you feel about nutrition right now?
FOOD BEHAVIORS check all that apply
Do you ever eat food then feel guilty?
Do you think some food is 'bad' and some is good?
Do you over exercise to 'burn off " food you ate?
Have you ever started a program, had an overage of food then quit?
Are you frustrated with dieting? Tell me about that?
Do you remember when you first started a diet? What age/circumstance?
Thank you for sharing.
How is your sleep?
Tell me about sleep.
Stress levels
GOALS
What are your goals right now? (check all that apply)
Tell me about your goals!
Headspace
What feels hardest right now?
Finish this sentence:"I just want to feel…"
Anything else you want to share?
How would you like support?
Feel free to tell me more of how I can help.
Do you ever feel like quitting?
How would you rate your confidence?
What is non negotiable for you?
Example: Lunch with the ladies each week. I don't want to diet. I don't want to stave. I like a glass of wine sometimes. I don't want to not be able to eat out in social situations.
What do you do for yourself?
Describe how you want to proceed. Examples: Tracy, balls to the wall. I want a whole program and dive head first in I just need direction. Or.. I'm trying to just do something, I really need some successes.. anything to get me moving forward. Or I can work on this 3-4 x a week and feel good.
For me, I want 4x a week for 30 min in the gym and 3-4 walks with my doggo. That's all I can do right now.
Do you eat /crave candy or sugar or cake?
Oh for sure I do. it's worse than it ever was! WHAT!
Does your SO or partner believe in you? Do they say negative things to you? Do you feel pressure to look a certain way to 'keep' them?
If that is too personal, no worries. This is a big concern for many women.
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Menopause & Strength Rebuild Assessment

FITNESS BASELINE

Nutrition baseline

GOALS

Headspace