Peri/Menopause Wellness Intake Form

Welcome!

This is a space for you to share your journey, experiences, and goals. Every woman’s path is unique, and I want to understand your story so I can support you in the most meaningful way. There are no right or wrong answers—just your truth.

Feel free to share as much or as little as you feel comfortable.

Name

Phone

Email

Date of Birth

Year

Month

Day

Date of Intake

Year

Month

Day

1. General Health & Lifestyle

How would you describe your current health?

Excellent

Good

Fair

Poor

Do you have any diagnosed medical conditions? (e.g., thyroid issues, diabetes, autoimmune conditions)

Are you currently taking any medications or supplements? If so, please list them.

How would you describe your eating habits?

Balanced

Inconsistent

Needs improvement

Do you engage in movement or exercise regularly?

Yes

No

If yes, what type and how often?

How many hours of sleep do you typically get per night?

Do you smoke or drink alcohol?

Yes

No

If yes, how frequently?

How would you describe your energy levels throughout the day?

2. Your Peri/Menopause Journey

Have you reached menopause?

Yes

No

Unsure

Are you currently in perimenopause?

Yes

No

Unsure

When was your last menstrual cycle?

Which of these symptoms are the most challenging for you?

Have you noticed any changes in your self-identity or confidence since entering peri/menopause?

What has been the most surprising or unexpected part of this transition for you?

3. Emotional & Mental Well-being

How would you describe your current emotional well-being?

Have you noticed increased anxiety, depression, or mood swings since peri/menopause began?

What are your biggest sources of stress right now?

Do you feel supported in your peri/menopause journey by family, friends, or healthcare providers?

What brings you joy, fulfillment, or a sense of peace in your life?

Are there areas where you feel stuck or overwhelmed?

4. Life Transitions & Childhood History

How would you describe your childhood in a few words?

What was the general atmosphere of your home growing up?

Did you experience any significant stressors in childhood (e.g., loss, family changes, illness, frequent moves)?

Who were your main sources of support as a child?

Who are your key sources of support now?

5. Hormone & Treatment History

Have you tried Hormone Replacement Therapy (HRT)?

Yes

No

Considering it

Have you explored any alternative therapies (e.g., herbal supplements, acupuncture, holistic treatments)? If so, what has worked for you?

Have you spoken to a doctor or specialist about your symptoms?

Yes

No

If yes, what was their advice?

6. Self-Care & Body Connection

How do you feel about your body and its changes at this stage of life?

What practices help you feel most grounded, peaceful, or connected to yourself?

How would you like to improve your self-care routine?

7. Life Goals & Coaching Expectations

What are your top 3 goals for working with a life coach?

What challenges or obstacles do you feel are holding you back?

How do you define success in your peri/menopause journey?

Thank You!

I appreciate you taking the time to share your journey. You are not alone in this process, and together, we will create a plan that supports you in feeling your best.