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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
https://wombhealthassessment.youcanbook.me
This is a confidential questionnaire and your responses will not be shared with or sold to anyone/business for any reason.
* Indicates required question
Email
*
Your email
Your Full Name
Your answer
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
Other:
Required
Do you have any other health concerns/pre-existing conditions that are contributing to your initial concern?
If yes, please list all.
Your answer
What does your current health/wellness/fitness routine look like?
Describe your eating habits, physical activity, spiritual practice, etc.
Your answer
Are you taking any herbs and/or medications? If yes, please list.
Your answer
Are you currently working with a primary care physician, OB/Gyn, Reproducive Endocrinologist, ets? If yes, please list. If no, why not?
Your answer
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
Your answer
What's working?
Your answer
Are you currently receiving mental and/or emotional support through a mental health specialist, peer support group, or other therapeutic setting?
Yes
No
Clear selection
What would you like to be different this time around?
Your answer
What are you willing to try? What are you not or no longer willing to do?
Your answer
How much time are you willing to give to get the results you're looking for?
4-6 weeks
3-6 months
>1 year
Clear selection
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
Clear selection
Are you ready to start working with me as your health coach RIGHT NOW? Why is now the best time?
*
Your answer
What would prevent you from seeking further treatment/support/guidance?
Your answer
Is there anything else you'd like to for me to know?
Your answer
A copy of your responses will be emailed to the address you provided.
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