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

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

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

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

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:

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

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