Full Name
Email
How did you hear about me? Social media
Friend / referral
Google
Other
What are you top 3 priorities you'd like to address? (sleep; energy; mood/irritability; brain fog; hot flashes/night sweats; weight; cycle changes; other)
Which symptoms interfere most with your daily life right now?
When did you first begin noticing these changes, and what was happening in your life at that time?
Current medications, supplements, or hormones:
Diagnosed medical conditions or ongoing health concerns:
Known allergies (food, environmental, medication):
How often do you drink alcohol? Rare (a few times a year)
Occasionally (couple times per month)
Socially
Never
Recreational drug use: No
Occasionally
Yes
Do you currently have a primary care provider? Yes
No
Date of last primary care visit:
Date of most recent lab work (if known):
How would you describe your sleep quality? (Include typical bedtime & wake time)
How many hours of sleep do you typically get per night? 4-5 hours
6-7 hours
8+ hours
Do you generally wake feeling rested? Yes
No
Currently eating patterns or dietary preferences:
Do you eat breakfast most days? Yes
No
Tell me about your current movement/exercise on a day to day basis. Do you make time for it?
What is your biggest barrier to movement/exercise? Time/childcare
Energy/fatigue
Joint pain/discomfort
Confidence/skills
Access/equipment
Motivation/consistency
Not sure
Current stress level: 1
2
3
4
5
6
7
8
9
10
How would you describe your relationship with your body right now? Trusting
Frustrated
Confused
Disconnected
Hopeful but unsure
When life becomes busy or stressful, which habits tend to fall apart first?
What has helped you feel better in the past -- but didn't last?
What do you feel has held you back from maintaining changes long-term?
On a scale from 1-10, how ready do you feel to make sustainable changes right now? 1
2
3
4
5
6
7
8
9
10
What type of support do you respond to best? (Check all that apply) Accountability check-ins
Encouragement & motivation
Practical tools & strategies
Education & understanding
Gentle guidance
Direct feedback
Preferred communication method: Email
Text
Phone
Video
What obstacles or challenges do you anticipate as you work toward your goals?
What questions or concerns do you have heading into this Deep Dive?
I consent to receive emails about scheduling, resources, and coaching. Yes
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