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WOMB AWAKENING RITUAL INTAKE FORM
First name
Last name
Email
Phone
1. MENSTRUAL & REPRODUCTIVE HEALTH
Cycle Basics
Age of first period:
Are your cycles:
Regular
Irregular
Unsure
"No cycle"
What to share more?
Average cycle length
Less than 21 days
21–35 days
More than 35 days
How many days does your bleeding last?
Flow
How would you describe your flow?
Very light
Moderate
Heavy
Very heavy
Do you experience:
Large clots
Frequent spotting
Flooding
Option 4
Bleeding between periods
Pain & Symptoms
Rate from 0–10:
Cramps:
Pelvic pain:
Breast tenderness:
Headaches/migraines:
Fatigue:
Mood swings:
Anxiety:
Bloating:
Insomnia:
Low libido:
Diagnosed Conditions
Have you been diagnosed with:
PCOS
Endometriosis
Fibroids
Adenomyosis
Ovarian cysts
BV
Recurring yeast infections
Thyroid imbalance
Perimenopause
Menopause
Fertility challenges
Other
Fertility & Pregnancy History
Have you experienced:
Pregnancy
Birth
Miscarriage
Abortion
IVF/Fertility treatment
Would you like to share more details?
VAGINAL & YONI HEALTH
Do you currently experience:
Dryness
Irritation
Odor
BV
Yeast infections
Itching
Pain during intimacy
Pelvic tension
Would you like to share more details?
Yoni Steaming Safety
Are you currently:
Pregnant
Trying to conceive
During active bleeding
Using an IUD
Recently postpartum
HORMONE & ENDOCRINE HEALTH
Check any symptoms that apply:
PMS
Mood swings
Anxiety
Depression
Hormonal acne
Weight gain
Sugar cravings
Low energy
Hot flashes
Night sweats
Hair thinning
Facial hair growth
Brain fog
Other
DIGESTION & DETOXIFICATION
How often do you have bowel movements?
Daily
Every other day
Less than 3 times weekly
Other
Do you experience:
Constipation
Bloating
Gas
Food sensitivities
Poor digestion
Other
How much water do you drink daily?
STRESS & NERVOUS SYSTEM
Current stress from 1 - 10 (1 being no stress)
Do you often feel:
Overwhelmed
Burnt out
Exhausted
Anxious
Disconnected from yourself
Emotionally numb
Hyper-independent
Difficulty resting
Other
How many hours of sleep do you get?
EMOTIONAL & WOMB WELLNESS
What season of life are you currently in?
Growth & Expansion
Transition
Healing
Grief
Reinvention
Motherhood
Menopause
Unsure
Want to share more?
Do you feel connected to your womb/body?
Very connected
Somewhat connected
Disconnected
Want to share more?
Are there any emotional experiences you feel may still be affecting your womb health?
LIFESTYLE
Current movement practices (walking, yoga, stretching, none...)
Nutrition style:
Omnivore
Vegetarian
Vegan
Pescatarian
want to share more?
How many cups of caffeine per day?
Alcohol & drugs consumption:
Are you currently taking any prescription medications or supplements? If yes, list:
Are you allergic to any herbs, plants, flowers, spices, or foods?
YOUR INTENTIONS
What support are you seeking in your life today?
What support are you seeking from this practice? (Painful periods, PMS relief, Hormone balance, Fertility support, Menopause support, Stress support, Nervous system regulation, Better energy, Vaginal wellness, spiritual work, Detox support ...
Send
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