Women's Health Treatment Selection Survey Form
Use this form to help select women’s health treatment options and capture the information needed to guide follow-up. The form should feel elegant, minimal, approachable, and polished.
Respondent Profile
Full Name
*
First Name
Last Name
Age Range
*
Under 18
18–24
25–34
35–44
45–54
55–64
65+
Preferred Contact Method
*
Email
Phone
Text Message
Postal Mail
Treatment Context
Main reason for exploring treatment
*
Symptom relief
Preventive care
Hormonal balance
Fertility support
Menstrual concerns
Menopause support
Other
Current treatment status
*
Not currently receiving treatment
Currently receiving treatment
Previously received treatment
Not sure
Primary concern or goal
*
Pain management
Cycle regulation
Symptom reduction
Improved energy
Fertility goals
Hormone-related concerns
Better quality of life
Other
Preference and Follow-up Details
Preferred treatment format
*
In-person
Virtual
Either
Preferred consultation date and time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Additional notes or questions
Contact email for follow-up
*
example@example.com
Submit Form
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