Name
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First Name
Last Name
Email Address
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Date of Birth & Age
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Weight (if would like to be different, also list ideal weight)
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Hobbies/Activities
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What are your main health concerns?
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What are the three main symptoms you'd like to heal? (please don't just say "endometriosis")
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Age of your first period
Are your periods regular?
How frequent?
How many days is your flow? Is it heavy, medium, or light?
You you experience PMS? If so, what are your symptoms?
Do you spot before you period? If so, for how many days?
Are you peri-, post-, or menopausal? If so, what are your symptoms?
Are you currently trying to get pregnant?
If not, are you planning on trying within the next year?
Do you track your basil body temperature?
How many total pregnancies?
Have you ever had a miscarriage? If so, how far along were you?
Do you have noticeable symptoms with ovulation?
Have you had an official laporoscopic diagnosis of endometriosis? If so, at what age?
What stage endo were you diagnosed with (1-4)?
Please list all of your surgeries related to endo, and if there were complications:
Have you had any of the following organs removed?
OVERALL PAIN: Average Overall Pain (scale of 1-10)
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Lowest Pain Level in last month
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Greatest pain level in last month
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CYCLIC PAIN: Pain prior to period
N/A
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Pain during period
N/A
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Pain after period
N/A
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10
Ovulatory pain
N/A
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PAIN WITH SEX:
PAIN WITH BOWEL MOVEMENT
Other Pain
Systemic symptoms
How many days per month, on average, are you pain free?
What helps improve your pain?
What makes your pain worse?
In making life changes, I usually perform the best when:
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Tell me how you best adopt changes so I can help create the best plan for you: All at once/full throttle, baby steps, moderate, etc
How much time do you have to dedicate to healing these next 3 months?
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As far as dietary changes in the healing process, this is my opinion:
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Tell me your thoughts: have never tried, have tried it all, am willing and open, am hesitant, etc
As far as lifestyle changes in the healing process, this is my opinion:
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Tell me your thoughts: have never tried, have tried it all, am willing and open, am hesitant, etc
As far as taking supplements to aid the healing process, this is my opinion:
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Tell me your thoughts: hate/won't ever take, will consider in moderation, want the full assortment, etc.
This is my ideal supplement $ budget/month during my healing phase (next 3-6 months)
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If I didn't have the symptoms I listed, my life would _____
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Tell me a little bit about what inspires you to heal. How do you imagine your life would be if you tackled your main health issues?
