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Client Intake Form
Hi beautiful! 

I'm really looking forward to our Menstrual Cycle journey together. 

Thank you for taking the time to fill out the intake form, this will allow me to learn a little bit about you before jumping into our first session.

Much love,

Diana

Email *
Personal Information
Email *
Birthday *
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Phone Number *
Location (City, State & Country) *
Postal Address  *
Emergency Contact 
(Full Name & Phone number)
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Health Background
Past Medical History *

Please check all that apply:

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Required

If you checked any of the above, please provide details:

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Do any reproductive health conditions run in your family? (e.g., infertility, early menopause, etc.)

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Do you take any supplements or medications? If yes, please list below: *
Lifestyle & Habits
How many hours do you sleep on average? *

Do you smoke? If yes, how many per day?

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Do you use recreational drugs? If yes, what & how often?

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Do you have any known allergies (food, medication, environmental, etc.)?

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Menstrual Cycle Awareness
On a scale of 1 to 5, how would you rate your current level of stress (1 = very little stress, 5 = very stressful) *
a little bit of stress
very stressful
Have you focused on your menstrual cycle before?
When was your last menstrual cycle? (Example: March 7, 2025)
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DD
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How long were your last three cycles? (Specify number of days & dates: Cycle starts from the first day of bleeding to the day before your next bleed.)

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How would you describe the regularity of your cycle? (e.g., consistently regular, varies, or irregular?)

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Do you have any concerns about your menstrual cycle?

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Are there any aspects of your cycle that you find positive or meaningful?

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Fertility & Contraception

Why are you interested in learning more about your menstrual cycle?

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Have you explored natural contraception & fertility awareness methods before? If so, please describe your experience.

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What contraception methods have you used in the past (if any)?

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Are you currently using any contraception? If so, which method?

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Have you had any pregnancies, births, or pregnancy losses?

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Have you or your partner had any STI/STDs?

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If yes, please share any relevant details:

Have you had any surgeries or procedures related to reproductive or hormonal health? If so, please provide details.

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Health & Wellness Goals

What is your #1 health goal you would like to achieve in the next 3-6 months?

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What are you needing the most support & guidance with?
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Are there particular concerns or challenges you'd like to work on through coaching?

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Why would you like to work with me one-on-one?
Other Modalities & Support

Have you sought support from any of the following?

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If you checked any above, please provide details on your experience.

Is there anything else you would like to to share with me?
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