Full name
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First Name
Last Name
Email
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Phone
*
(###)
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Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
(###)
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Date of Birth
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Occupation
How did you hear about me and this work?
Preferred Pronouns
Gender currently identifying as
Gender assigned at birth
What is your primary reason for this visit?
What would you like to achieve as a result of this visit?
When did you first notice this?
Do you feel something may have triggered this?
Describe any stressors you are experiencing at this time.
What makes you feel better?
What makes you feel worse?
What changes or goals would you like to achieve over the next 3-6 months?
Please list any medication, vitamins, supplements, or natural remedies that you take.
Do you use alcohol or recreational drugs? If so, how regularly and how do you feel about this?
Do you smoke? If so, how often and how do you feel about this?
Any allergies? What are you allergic to (or sensitive to) and what reaction do you have?
Any history of surgery? If so, what kind and approximate date?
Accidents? Any injury to sacrum/tailbone?
Do you, or have you ever suffered from any of the following:
Please elaborate on any checked boxes.
Please share any significant details of your birth family story if known: this may include physical or mental health, lifestyle, cause/age of death or any other details you feel are relevant. Use this box for your maternal side details.
Same question, but for paternal side.
Describe your relationship with food.
What were meal times like growing up? What are they like now?
Do you have any food intolerances or allergies?
Do you eat home cooked meals?
Do you follow a particular diet?
Typical daily water intake?
Average daily caffeine intake?
Alcohol consumption?
Do you experience any bloating, burps, or flatulence after eating?
If so, what triggers this?
How often are your bowel movements?
Do you suffer from any of the following?
How do you nurture yourself?
Are you currently experiencing stress?
How does this affect your life and how to you manage it?
Do you have a faith or spiritual practice and if so, would you be wiling to share this?
What exercise do you enjoy and how often do you do it?
Do you experience low mood, anxiety, depression, post-traumatic stress disorder, or any other mental health condition that you are willing to share?
Have you experienced any traumatic events that you would be willing to share?
Have you considered or are currently seeking professional support?
Do you experience pelvic pain or congestion? If so, how does this affect you?
Do you feel pain in any of the following areas?
How does this affect you?
Do you experience any of the following urinary issues?
How does this affect you?
Have you had any of the following pelvic tests?
Have you had any abnormal results? Did you rceive any treatment?
Do you currently have or have you ever used any of the following forms of birth control?
If hormonal, which kind?
Do you experience any of the following?
Elaborate on any checked boxes.
How old were you when you started menstruating? What was that like for you?
How many days is your menstrual cycle?
How many days is your bleed?
How many days do you spot prior to or at the end of your period?
What menstrual products do you use?
Do you bleed through more than one tampon or pad per hour?
Date of your last period?
How do you feel about your menstrual cycle?
Do you chart your cycle and if so, how? (app, paper chart, etc.)
Do you know if your mother, sister, or any other close female relation have experienced any of the following issues?
Do you experience or have a history of any of the following:
Any additional info about any checked boxes above?
Do you enjoy sex?
Do you orgasm?
Are you satisfied with your level of sexual desire?
Have you noticed any changes recently?
How do you feel about this?
Are you hoping to conceive?
Have you or your partner had any pregnancies?
If so, did you choose to continue with them and what were they like?
Have you experienced any loss?
Have you witnessed or given birth? Please provide any info you would like to share such as birthdates, birth outcomes (induction/spontaneous labor, vaginal/cesarean/VBAC)
If so, what was the experience(s) like?
Postpartum experiences?
Have you had any fertility tests e.g. sperm or egg reserve?
Are you under the care of a fertility specialist?
Please describe any treatment you received including IUI, IVF, ICSI, hormone treatment or surgery.
How do you feel about your menopause journey?
What positive menopause role models do you have?
Are you keeping a menopause journal?
Are you experiencing any of the following?
When did you start noticing symptoms?
Are they changing, increasing, decreasing?
Have you noticed a connection between your symptoms and:
Do you use or have you ever used hormone replacement therapy or bio-identical hormones? If so which ones and for how long?
I am SO appreciative you took the time to complete this form. Is there anything else you would like to share with me or elaborate on?
