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Health History Form

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Health History Form

Health & Wellness Intake Form

Thank you for taking a few minutes to share about yourself. This form helps me understand your story so I can better support you. It should take about 5–10 minutes to complete.

"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

About You

Full Name

First

Date of Birth

MM slash DD slash YYYY

Best way to reach you (phone/email)

First

Email*

How Can I Support You?

What brings you here today?

General wellness

Improving energy and mood

Digestive/Gut health

Weight loss

Balancing hormones

Menstrual cycle concerns (pain, irregularity, heavy flow, etc.)

Fertility, pregnancy, or postpartum support

Navigating perimenopause or menopause

Improving energy and mood

Other (please specify)

Please Specify

In your own words, what feels most important right now?

Your Health Story

Allergies (food, medications, environment)

Current medications or supplements

Past illnesses, surgeries, or hospitalizations

Family health history (e.g., hormonal, heart, cancer)

Women’s Health

Age at first menstrual period

Cycle length & regularity

Last period

MM slash DD slash YYYY

Symptoms before or during your cycle

Contraception history (current or past)

Pregnancy history (pregnancies, births, miscarriages, complications)

Menopause / perimenopause experiences

Daily Rhythms & Lifestyle

Typical day of eating

Movement / exercise

Sleep (hours, quality)

Stress level / main sources of stress

Emotional well-being (mood / mental health)

Alcohol / tobacco / recreational use

Current Wellness Check-In

Do you experience any of the following?

Fatigue / low energy

Sleep struggles

Hot flashes / night sweats

Weight changes

Low libido

Digestive discomfort

Mood swings / anxiety

Skin or hair changes

Other (please specify)

Please Specify*

Looking Ahead

Top 1–2 short-term goals (next 3 months)

Long-term goals (6–12 months)

How would you like me to support you?

Nutrition & meal guidance

Hormone / cycle education

Lifestyle coaching (stress, sleep, movement)

Referrals or testing recommendations

Accountability & encouragement

Other

Next Steps

Thank you for sharing your story. Everything you write here will stay confidential and is used only to create a personalized wellness plan for you.

Signature

Date

MM slash DD slash YYYY

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Health History Form

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