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Intake Questionnaire

This is where we begin.

To begin working together, please complete this intake form. 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.

Birthday
Month
Day
Year
What symptoms are you currently experiencing?
Do you ever skip meals?
Yes
No
Do you eat breakfast within 30-60 minutes of waking on a REGULAR BASIS?
Do you feel bloated after eating and/or feel sluggish after heavy meals?
Are your cycles:
Regular
Irregular
Missing
Any history of hormonal birth control use?
Yes
No
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