This intake focuses on hormonal and cycle-related changes, including sleep disruption, emotional shifts, and physical changes that often arise during perimenopause or other hormonal transitions.

There are no right or wrong answers. Please respond based on your lived experience. You do not need to analyze or interpret your symptoms — simply describe what you have noticed.

First Name

Last Name

Phone number

Date of Birth

SECTION 1 — What brings you here now

1. What prompted you to seek care at this time?

SECTION 2 — Menstrual cycle & hormonal changes

2. What best describes your current menstrual status?

Regular cycles

Irregular cycles

Skipped cycles

Cycles have stopped

Unsure / difficult to tell

3. If you are still menstruating, have you noticed changes over the last few years? (Select all that apply)

Changes in cycle length

Changes in flow (heavier / lighter)

Increased PMS

New symptoms before or after menstruation

Cycles feel unpredictable

No significant change

4. If your cycles have stopped, when did this occur (approximately)?

5. Do your symptoms seem connected to certain points in your cycle, or do they feel more constant?

SECTION 3 — Sleep patterns

6. How is your sleep currently affected? (Select all that apply)

Difficulty falling asleep

Waking between 1–4 am

Early waking with inability to return to sleep

Waking with anxiety or a racing mind

Waking with heat or sweating

Feeling unrefreshed despite sleep

Sleep is not a major issue

7. How long has sleep disruption been present (if applicable)?

Less than 6 months

6–12 months

More than 1 year

Not applicable

SECTION 4 — Emotional & nervous system changes

8. Have you noticed any of the following emotional or stress-related changes? (Select all that apply)

Increased irritability or reactivity

Feeling emotionally “unlike myself”

Reduced tolerance for stress

Heightened sensitivity to others or surroundings

Anxiety that feels new or unfamiliar

Emotional flatness or withdrawal

No significant emotional changes

9. If emotional changes are present, how do they affect your daily life? (Open text)

SECTION 5 — Physical changes that feel unfamiliar or confusing

10. Have you noticed any of the following physical changes? (Select all that apply)

Weight redistribution (especially abdomen)

Bloating or digestive discomfort

Heat intolerance or hot flashes

Palpitations or internal restlessness

Muscle tension that does not release

Fatigue that does not improve with rest

Changes in skin or hair

None of the above

11. Are there any physical changes that concern or confuse you most? (Open text)

SECTION 6 — What you’ve tried so far

12. What have you tried to address these hormonal or cycle-related changes? (Examples: lifestyle changes, supplements, medications, hormone therapy, other therapies — brief description is sufficient)

SECTION 7 — Medical & treatment context

13. Are you currently using any of the following? (Select all that apply)

Hormone replacement therapy (HRT)

Birth control (current or recent)

Thyroid medication

Antidepressants or anti-anxiety medication

Regular supplements

None of the above

14. Please list current medications and supplements, including dosages if known.

15. Have you been diagnosed with any significant medical conditions?

SECTION 8 — The meaning question (do not skip)

16. What worries you most about these changes, or what feels most unsettling to you right now?

SECTION 9 — Expectations & logistics

17. What are you hoping to gain from working together?

18. Is there anything else you feel is important for me to know before our consultation?

Disclosure and Informed Consent:

Homeopathy is a system of complementary care and is not intended to replace medical diagnosis, treatment, or emergency care.

Homeopathic care is individualized, and responses to treatment vary from person to person. No guarantees are made regarding specific outcomes.

I confirm that the information I have provided is accurate and I consent to receive homeopathic services from Homeopathy for Better Health.

Consent & Authorization

I have read and understand the information above and consent to receive homeopathic services from Homeopathy for Better Health.

Full Name (Electronic Signature)

Date

Women’s Hormonal Health Intake