Functional Fertility & Early Pregnancy Intake Questionnaire
This form helps me understand your body, lifestyle, and goals so I can support you safely and holistically during conception and early pregnancy. Please answer honestly — there are no right or wrong answers.
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Basic Information
Full Name:
Preferred Name:
Email:
example@example.com
Phone Number:
City / Country:
Time Zone:
Occupation:
Typical Work Schedule:
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Conception / Pregnancy Status
Current status (Trying to conceive / Pregnant / Unsure):
If pregnant, estimated weeks pregnant:
Is this pregnancy considered high-risk? If yes or unsure, please explain:
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Pregnancy History
Number of previous pregnancies:
Number of live births:
Any pregnancy losses or complications? Please explain:
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Body Metrics
Height:
Pre-pregnancy or current weight:
Recent weight changes (stable/gain/loss):
Do you feel weight impacts hormones or energy?
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Hormone & Cycle Health
Average cycle length (if applicable):
Are cycles regular?
Common symptoms (PMS, pain, heavy bleeding, etc.):
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Energy, Mood & Nervous System
Energy level (1-10):
Stress level (1-10):
Mood stability (1-10):
Symptoms (brain fog, anxiety, ADHD, poor sleep, etc.):
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Nutrition & Appetite
Meals per day:
Do you skip meals?
Current cravings or aversions:
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Supplements & Medications
Current supplements (include dosage if known):
Prenatal vitamin?
Prescription medications:
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Digestion & Blood Sugar
Digestive symptoms (bloating, constipation, reflux, etc.):
How soon do you feel hungry after eating?
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Sleep & Movement
Average bedtime:
Wake time:
Night wakings?
Current activity level and preferred movement:
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Health History & Goals
Any diagnosed conditions (thyroid, autoimmune, anemia, etc.):
Family health history:
Top 3 goals during this phase:
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Final Notes
Is there anything else you'd like me to know about your journey?
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