Client Intake Form

Client Intake & Product Guidance Form

These questions help me understand your cycle, symptoms, and energetic patterns so I can guide you toward the products that will support your body most deeply. Please answer whatever you feel comfortable sharing.
Name
Email
example@example.com
Phone
Format: (000) 000-0000.
Date

MonthDayYear
Date
Cycle & Hormonal Rhythm 1. Do you currently have a menstrual cycle?

Irregular 2. If yes, what is the average length of your cycle? Last 3 cycle dates?
YesNoIrregular
2. If yes, what is the average length of your cycle? Last 3 cycle dates?
PMS or mood shiftsPainful cyclesHeavy bleedingVery light or short bleedingMissing periodsMid-cycle spottingFatigue around cyclePCOS, FibroidsEndometriosisOvulation pain
4. What phase do you feel most supported... and least supported?
BloatingConstipationLoose stoolsHeartburnSugar cravingsLow appetite / sluggish digestion
AnxietyAnger / irritabilityFeeling stuckGriefNumbnessOverwhelmLack of motivation
Sympathetic (activated, go-go-go)Parasympathetic (slow, tired, withdrawn)
8. How is your sleep?
Womb tension or pelvic heavinessLow libidoHeart heaviness or emotional tightness in the chestBurnout or adrenal fatigue symptomsBreast tendernessBloating around luteal phase
Womb tension or pelvic heaviness

Heart heaviness or emotional tightness in the chest Burnout or adrenal fatigue symptoms

Bloating around luteal phase 10. Have you had any recent infections (yeast, BV, UTI, etc?
10. Have you had any recent infections (yeast, BV, UTI, etc.)?
11. Do you take time for daily grounding or ritual? If so, what does that look like?
12. Do you do any creative projects, dance, sing, and/or workout?
More regular cyclesLess painEmotional ease/regulationBetter digestionMore energyHeart openingWomb clearingFertility supportFeeling connected to your feminine energy
14. Anything else you'd like me to know about your body, emotions, or current healing season?
15. Are you pregnant or breastfeeding?
16. Are you on any medications or have allergies?
Should be Empty: