Women's Health and Menopause Intake Form

Navigating the journey through perimenopause to postmenopause can be complex, and this form is designed to help us understand your unique health experience. We know it may feel like a lot, but each question is intended to ensure we can provide personalized support that addresses your specific needs, challenges, and wellness goals. By sharing this information, you're taking an important step in creating a tailored coaching plan to guide you through this transformative time, helping you feel empowered and supported every step of the way. Thank you for entrusting us with this important part of your health journey!

Date

Month

Day

Year

First name

Last name

Email

Phone

Birthday

Month

Day

Year

How would you describe your current menstrual status?

Premenopause (having regular periods)

Premenopause (no periods due to hormonal birth control)

Perimenopause (having irregular periods &/or symptoms)

Perimenopause (symptoms but no periods due to hormonal birth control)

Postmenopausal (no periods in over 12 months)

If postmenopausal, was it:

N/A

Spontaneous (occurred naturally)

Surgical (removal of both ovaries)

Due to chemotherapy or radiation therapy

Age at first menstrual period

Age your mother finished menopause?

If you are not able to contact your mother please put I don't know.

Do (or did) you experience PMS?

Yes

No

I don't know

Please describe your menstrual periods:

Light, heavy, short, long, irregular, painful, etc.

What reproductive organs do you currently have?

Both Ovaries

Cervix

Uterus

Select all that apply

Do you conduct regular breast self-exams?

Yes

No

What supplements and/or medications are you taking specifically for women's health and/or menopause?

Please also note if you are on HRT and/or SSRIs.

Have you had a bone density tests or screenings related to menopause health?

How many hours of sleep do you average per night?

≤5

6-7

8+

Do you currently use any fitness trackers?

Select all that apply

Symptom Experiences

Below are all potential symptoms that you could be experiencing during perimenopause and beyond. Please take your time to go through each one and answer the most fitting answer as of now:

Do you currently experience belly fat retention?

Do you currently experience bladder leaking?

Do you currently experience brain fog?

Do you currently experience breast tenderness?

Do you currently experience cold sweats or flashes?

Do you currently experience cry attacks that come on for no reason?

Do you currently experience a decreased sex drive?

Do you currently experience difficulty concentrating?

Do you currently experience difficulty falling asleep?

Do you currently experience difficulty staying asleep?

Do you currently experience digestive issues?

Do you currently experience dry mouth and/or skin?

Do you currently experience dizziness and/or vertigo?

Do you currently experience facial hair growth?

Do you currently experience forgetfulness or memory issues?

Do you currently experience hair thinning and/or loss?

Do you currently experience headaches and/or migraines?

Do you currently experience heart palpitations?

Do you currently experience hot flashes?

Do you currently experience irritability?

Do you currently experience itchy ears and/or skin?

Do you currently experience joint pain?

Do you currently experience mood swings?

Do you currently feel more anxious than usual?

Do you currently feel more sad and/or depressed than usual?

Do you currently experience muscle aches?

Do you currently experience night sweats?

Do you currently experience oral sensitivity?

Do you currently experience pain and/or discomfort during sex?

Do you currently experience panic attacks?

Do you currently experience phantom bug bites or crawling sensations?

Do you currently experience phantom smells?

Do you currently experience phantom tastes?

Do you currently experience rage outbursts?

Do you currently experience sensitivity to sounds?

Do you currently experience shocking, tingling, or pins & needles sensations?

Do you currently experience spotting after sex?

Do you currently experience urges to urinate?

Do you currently experience vaginal dryness?

Do you currently experience vaginal itching?

Do you currently experience weight gain?

Do you frequently get bacterial vaginosis?

Do you frequently get UTIs?

Do you frequently get yeast infections?

How would you rate your typical energy levels?

Low

Moderate

High

At what age did you begin experiencing these symptoms?

How do you view menopause?

Positively

Negatively

Neutral

Describe your peri/menopausal experience so far:

What are your concerns about menopause?

What are your views regarding menopausal hormone replacement therapy?

Have you experienced a traumatic event in the last 5 years?

Such as loss of a loved one, job changes, divorce, relocation, etc.

What else would you like us to know about your experience that wasn't covered above?

What would be your ideal outcome from working together?

Yes, subscribe me to receive exclusive educational resources, expert tips, and personalized support designed specifically for my menopause journey.

I acknowledge that I have read and agree to the terms of the Liability and Scope of Practice Waiver. I understand that coaching services do not replace medical advice, and I take full responsibility for consulting my healthcare provider as needed.

Women's Health and Menopause Intake Form

Symptom Experiences

Subscribe for health tips & updates: