Menopause Intake Form
Please complete this form to help us assess your menopause-related health and symptoms.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
When did you have your last menstrual period?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please indicate any menopause-related symptoms you are currently experiencing:
*
Hot flashes
Night sweats
Irregular periods
Mood changes
Sleep disturbances
Vaginal dryness
Decreased libido
Weight gain
Memory issues
Other
Please rate the severity of your menopause symptoms overall:
*
None
1
2
3
4
5
6
7
8
9
Severe
10
1 is None, 10 is Severe
Do you have any of the following medical conditions?
High blood pressure
Diabetes
Thyroid disorder
Osteoporosis
Heart disease
Cancer
None of the above
Other
Are you currently taking any hormone treatments or supplements? If yes, please specify.
Please provide details of any surgeries (such as hysterectomy, oophorectomy) you have had, if applicable.
Do you have a family history of any of the following?
Early menopause
Breast cancer
Osteoporosis
None of the above
Other
Lifestyle factors: Please select all that apply to you.
Currently smoke
Drink alcohol regularly
Exercise regularly
Follow a special diet
None of the above
What are your main concerns or goals regarding menopause?
Submit Intake Form
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