Consultation Intake Form

Cycle Health/Pre-Conception Intake Form

Please fill out this intake form with as much information as you can, the more background you share the more I can help you! I will respond to your intake form within 48 hours with follow up questions before making my recommendations.

* Indicates required field

Name *

First

Last

Email *

Age *

Sexually Active? *

Yes

Marital status *

I am currently: *

Pregnant Breastfeeding Newly post-partum

Number of Children *

Miscarriages *

Abortions *

Have you ever had any fertility challenges? *

Constitution

I tend to run: *

hot cold neutral/I don't know

Overall, I typically feel: *

Dry Damp Neutral/I don't know

In my body, I commonly feel: *

Tension Laxity Neutral/I don't know

Notes *

Diet and Lifestyle

Allergies or food sensitivities: *

Typical diet: *

Describe level of movement/exercise in a typical day or week: *

Menstrual Cycle History

Age of first period: *

Length of period *

Cycle Range *

Preferred period products *

Other: *

Do you chart your cycle? *

I track my periods I chart cervical mucus I chart basal body temperature I practice NFP/Fertility Awareness

Upload recent chart *

Max file size: 20MB

Birth Control History

Have you ever used any kind of birth control? *

List types of birth control used, when used, and any side effects experienced: *

Basic Health Information

List any underyling symptoms, health diagnoses or concerns: *

List any medications you are taking: *

List any herbs or supplements you are using regularly: *

Please Share your reason for desiring a consultation, your health goals, your specific questions, etc. *

Submit