Womb Health Assessment -- Pre-Screening Questionnaire
The purpose of this pre-screening questionnaire is to quickly determine if working with me is a good fit for where you are on your wellness journey before making the financial commitment.
Please use the same email address used when booking your appointment. If you haven't booked an appointment, please do so at
This is a confidential questionnaire and your responses will not be shared with or sold to anyone/business for any reason.
Your Full Name
Purpose of booking Womb Health Assessment:
Please check all that apply
Support with PMS/period problems
Resolve symptoms of PCOS
TTC with PCOS
Preparing for conception/pregnancy
Do you have any other health concerns/pre-existing conditions that are contributing to your initial concern?
If yes, please list all.
What does your current health/wellness/fitness routine look like?
Describe your eating habits, physical activity, spiritual practice, etc.
Are you taking any herbs and/or medications? If yes, please list.
Are you currently working with a primary care physician, OB/Gyn, Reproducive Endocrinologist, ets? If yes, please list. If no, why not?
What have you tried currently or in the past to resolve your health concern?
Please include all books, diets, programs, supplements, treatments, therapies, etc that you've tried
Are you currently receiving mental and/or emotional support through a mental health specialist, peer support group, or other therapeutic setting?
What would you like to be different this time around?
What are you willing to try? What are you not or no longer willing to do?
How much time are you willing to give to get the results you're looking for?
How much are you willing to invest in a wellness program?
This includes coaching fees, groceries, therapeutic treatments, etc
$500+ a month
$250-500 a month
<$250 a month
Are you ready to start working with me as your health coach RIGHT NOW? Why is now the best time?
What would prevent you from seeking further treatment/support/guidance?
Is there anything else you'd like to for me to know?
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Melissa Danielle.