Intake Form | My Site

Welcome

This form helps me understand where you are in your perimenopause or menopause journey. The more I know about your unique situation, the better I can support and guide you.

First name

Last name

Phone Number

What’s important for me to know before your first appointment?

Please describe, in your own words, what is worrying you most right now.

This might include symptoms, health concerns, fears about treatment, or experiences such as being told you can’t take hormone therapy.

During our initial consultation, with your consent, I will be asking about your current and past health concerns. This helps ensure that any support or recommendations are safe, appropriate, and tailored to you.

Family medical history

I’ll also ask about relevant medical history of your close family members.

Some conditions, such as certain cancers, heart disease, clots or osteoporosis can have a genetic component. Understanding whether these are present in your family helps me better assess your individual risk and guide your care.

If you can, gathering any relevant family health information ahead of time may be helpful.

What is your preferred contact method?

Phone

Text message