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FEMALE INTAKE FORM

Section 1: Personal & Reproductive Health History

Date of Birth
Month
Day
Year
Are you currently menstruating?
Are your periods regular?
Do you experience:
Have you entered menopause?
Have you ever been pregnant?
Are you currently using birth control or hormone replacement therapy?

Section 2: Hormonal & Reproductive Symptoms

0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

PMS or mood changes before your period
Bloating or water retention
Headaches or Migraines
Hot flashes or night sweats
Vaginal dryness or discomfort
Low libido or changes in sexual desire
Hair thinning or loss
Acne or oily skin
Unexplained weight gain or difficulty losing weight
Fatigue or energy crashes during the day
Sleep disturbances (falling or staying asleep)

Section 3: Thyroid & Metabolic Function

0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

Sensitivity to cold or heat
Unexplained weight changes
Hair loss or brittle nails
Constipation or sluggish digestion
Brain fog or slowed thinking
Feeling anxious, nervous, or irritable
Feeling sluggish or depressed
Family history of thyroid disease?

Section 4: Gut & Detox Function

0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

Bloating, gas, or indigestion
Constipation or irregular bowel movements
Food cravings or intolerances
Sugar or carbohydrate cravings
Skin rashes or acne flare-ups
History of antibiotic use
Alcohol consumption

Section 5: Stress, Adrenals & Emotional Health

0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

Feeling "tired but wired" at night
Afternoon energy slumps
Salt or sugar cravings
Dizziness when standing up quickly
Difficulty handling stress
Anxiety, irritability, or mood swings
Difficulty concentrating or staying focused
Do you practice any stress management techniques?

Section 6: Lifestyle & Habits

Sleep

Movement

Nutrition

Caffeine / Alcohol / Smoking & Vaping

Add your text

Do you currently smoke, vape or use nicotine?

Supplements

Section 7: Family & Medical Background

Section 8: Wellness Priorities

Consent

This questionnaire is designed to help us better understand your unique hormonal and metabolic profile, lifestyle factors, and overall wellness.​  Please answer each question as accurately as possible.  Your responses will guide your personalized plan for hormonal balance, vitality, and longevity.

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All information is strictly confidential and reviewed by Dr. Sandra Mckenzie.

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