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Health & Wellness Form

Please fill out the questions below to help me understand your health profile and symptoms. All information remains strictly confidential. Let’s get started!

What stage are your periods?
They are regular
They are irregular or changing
I have not had a period or any bleeding for more than 12 months
I'm on contraception and not having any periods or breaks
I have started bleeding again after 12mths or longer
Are you taking HRT? (now or previously)
Yes
No
Are you taking a contraceptive pill or using an IUD/coil?
Yes - contraceptive pill
Yes - IUD
No
Other
Do you have any history of DTV, VTE or clots
Yes
No
Do you have a history of blood pressure?
High blood pressure
Low blood pressure
Normal
Do you have any history of cancer?
Yes
No
Is there a family history of any of the following?
Have you ever been diagnosed with any form of; depression, mental illness, postnatal, ADHD, PTSD or other?
Yes
No
Have you been diagnosed with any of the following
Have you been diagnosed with Long Covid?
Yes
No
Have you had a hysterectomy
Please select all the symptoms you have
Please select any vaginal health symptoms you have/had?
Are you taking any vitamins or supplements?
Yes
No
How often do you exercise?
Daily
Weekly
Monthly
Not at all
How often do you drink alcohol?
Daily
Weekly
Special occasions / rarely
Never
On most days how much sleep do you get?
Less than 4 hours
4 - 6 hours
6 - 8 hours
More than 8 hours
How would you describe your sleep quality?
Sleep uninterrupted - very good
Waking up once to pee - good
Waking multiple times to pee - not good
Waking up alot and struggling to go back to sleep - poor
Can barely get any quality sleep - bad

By submitting this form, you acknowledge our Terms & Conditions and understand that any guidance from Womankind does not replace medical diagnosis or treatment from your GP or medical specialist. As a certified Menopause Wellness Consultant, holistic coach & practitioner, I provide supportive, evidence-based options to discuss with your healthcare team. Your data is kept strictly confidential 

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