top of page

Health & Wellness Form

Please fill out the questions below as openly as possible to help me understand your health and symptoms. Your answers will allow me to offer you the best support tailored to your needs. Rest assured, all information is kept private and confidential. Let’s get started!

Birthday
Day
Month
Year
What stage of menopause do you think you are?
Perimenopause - you still have periods, even if irregular, average ages 37 - 51yrs
Menopause - you have not had any periods or spotting for 12 consecutive months or more, average age 51 - 52yrs
Post menopause - well over 12 months of absolutely no bleeding, average age over 51 yrs
Medically induced menopause - hysterectomy, other treatment
No idea
Are you currently taking HRT
Yes
No
Are you taking any contraceptive hormones or have in 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 breast cancer?
Yes
No
Have you ever been diagnosed with depression, mental illness, postpartum?
Yes
No
Have you been diagnosed with Long Covid?
Yes
No
Have you had a hysterectomy
Please select all the symptoms you have
Vaginal health - select any of these you have been suffering with.
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
bottom of page