Client Intake Form Client Name * First Name Last Name Email * Phone * Country (###) ### #### What is your age ? What stage of Menopause are you in ? Perimenopause Menopause Post Menopause Unsure Have you entered Menopause surgically ? Yes No Do you have any of the following pre-existing conditions ? High blood pressure Heart disease Osteoporosis or osteopenia Diabetes or prediabetes Thyroid disorders Autoimmune conditions History of breast, ovarian or uterine cancer Blood clotting disorders (eg: stroke) Other Other - please explain Do you have a family medical history of any of the following : Cardiovascular Disease - Stroke High Blood Pressure Diabetes High Cholestrol Blood Clots Gastrointestinal Conditions - Gut & Liver Health Heart Palpitations or Dizziness Mood Disorders (Depression/Anxiety) Kidney Conditions Thyroid Disorders Respiratory Disorders (eg: Asthma) Immune Health Disorders Migraines or Headaches Bone, Joint or Musculo-Skeletal Low Bone Density Please list any Health and/or Injury Specialists you are currently engages with ? Are you currently taking any prescribed medications, supplements or HRT/MHT ? Do you have any allergies (medications, foods, supplements) ? Does your menstrual history include any of the following ? Amenorrhea Menorrhagia PCOS Endometriosis Infertility What are your concern(s) regarding Menopause ? Menopause Symptoms Assessment Hot Flushes/Flash Brain Fog Low Energy/Fatigue Lack of Motivations Anxiety Feeling 'low' Irritability Headaches Numbness/tingling Disrupted sleep/insomnia Weight gain Loss of muscles Burning or aching joints/muscles Restless legs Low libido Worsening prolapse Vaginal dryness Thinning hair/hair loss How often do you exercise per week ? 0 days 1 - 2 days 3 - 4 days 5 + days What exercise modalities do you engage in ? How would you describe your diet ? Balanced (Whole foods, variety of nutrients) Mostly processed foods Vegetarian/Vegan Keto/Low carb Other Thank you!