FEMALE INTAKE FORM

Hello, Friend!

Welcome to your first step toward a healthier, happier you! This questionnaire is designed to help me get to know you better so I can create a personalized plan tailored to your unique needs. Remember, meaningful change happens one small step at a time, and those small steps lead to lasting habits.

By filling out this form, you’re giving me the insight needed to assess which changes will benefit you the most—and together, we’ll walk this journey step by step. I’m here to support you every step of the way!

Personal Information

First name

Last name

Address (City, State, Zip Code)

Phone

Birthday

Month

Day

Year

Height

Weight

Medications (and the reasons for taking them)

Supplements (e.g., vitamins, minerals)

Lifestyle & Routine

What are your working hours?

How long do you typically sleep at night?

Do you often wake up during sleep? If so, can you easily fall back asleep?

When do you usually go to bed?

Do you wake up feeling rested or tired?

Nutrition and Diet

What does a typical breakfast look like for you?

What does a typical lunch look like?

What does a typical dinner look like?

Do you snack? If so, what do you usually reach for?

(Optional) If possible, please spend one week prior to our visit documenting your food. If this isn’t feasible, sharing an average idea will still be helpful.

Physical Activity

How active are you during a typical day?

Do you exercise? If yes, how often and what types of activities do you enjoy or currently do?

Do you have any physical conditions or limitations that might affect your ability to exercise?

Health Concerns

Do you have any concerns about your weight?

Do you have any concerns about your diet?

Do you have any other concerns or symptoms you want to address?

Hormones

Do you still have a monthly cycle?

Do you have any concerns about your hormones or cycle?

If you’ve entered menopause, how long ago was it?

Healthcare Team

Do you have a primary care provider? If so, who?

Do you have any specialty providers? If so, who?

Additional Information

Is there anything else you’d like me to know about your health, lifestyle, or goals?