Intake Questionnaire

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Intake Questionnaire

This is where we begin.

This questionnaire is a space to slow down and share what your body has been experiencing, along with what you’re hoping for moving toward.

I’ll review your responses thoughtfully and be in touch with next steps.

First name

Last name

Phone

Birthday

Month

Day

Year

What are your main health goals right now?

What symptoms are you currently experiencing?

Fatigue

Weight gain or difficulty losing weight

Cravings (especially sugar/carbs)

Irregular Cycle

Acne

Infertility

Hair thinning/excess hair growth

Mood swings/anxiety

Poor sleep

How long are your breaks between eating? (snacks included)

Do you ever skip meals?

Yes

How much protein do you get each meal?

10-15 grams

15-20 grams

25-30 grams

30+ grams

not currently tracking

How do you rate your daily stress load? Are you able to easily regulate your stress/nervous system when needed?

What are your sleep patterns? How much regular sleep do you get?

Have you experienced traumatic events or periods of intense and chronic stress?

Are your cycles:

Regular

Irregular

Missing

Do you have PMS symptoms? If yes, please elaborate.

Have you tracked or are you aware of your ovulation patterns?

Any history of hormonal birth control use?

Yes

Please list any diagnoses. (PCOS, Insulin Resistance, Pre-diabetes, Thyroid imbalances, etc.)

What made you decide to seek support right now?

What are you hoping for in the next 3-6 months?

What has not worked well for you in the past or with past practitioners?

Are you currently taking any medications or supplements?

What feels hardest for you right now in regards to your health?

Is there anything you'd like me to know that hasn't been addressed in the above section?

@lex.mere

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