Intake form Please fill out the intake form and agree to the terms. * indicates required field Name:* Email:* Birth date Address How did you find fertility awareness and Holistic Hormonal Health: What do you want to use fertility awareness for? Birth control Trying to conceive Will be trying to conceive Hormonal Monitoring Height Weight Age of first period Typical cycle length Are you already charting your cycles? If so, since when? Length of typical period? Heavy, moderate, light? Check any that apply Cramps Heavy Bleeding Vulvovaginal pain Painful intercourse Frequent UTIs Clotting Irregular bleeding Irregular discharge PMS Other If you checked "other," please describe Do you have any known conditions such as PCOS, endometriosis, fibroids, or ovarian cysts? Number of pregnancies, births, and abortions? Past contraception use? Please list any medications you are on including supplements, vitamins, and herbs Alcohol/caffeine/nicotine/marijuana/drugs/antibiotics/painkillers? How often and/or when? Any past surgeries (especially anything vulvovaginal)? Known allergies or sensitivities? Any history with STIs? Any gynecological conditions in your family? Typical exercise or activity? Typical diet? Are you under a lot of stress? Generally relaxed? How much sleep do you get? Do you sleep in absolute darkness? Do you have trouble falling and/or staying asleep? Is there anything else you think might be relevant? Do you have a primary concern or question? Disclaimer: While I will educate you in how to use the sympto-thermal method of birth control, pregnancy, achievement, or assessing hormonal health, ultimately you assume all risk and liability about using this information. I do not make any warranty about how this information will work for you. I shall not in any way be held liable for any damage suffered by any person choosing to use any of the information that I teach. While the sympto-thermal method is a highly accurate form of birth control, as with any other method it is not foolproof and there is a chance that the method will fail. I will not be held responsible for any failure of the method. All verbal and written information, in the context of our professional relationship, will be kept confidential. I will not share information concerning you including the fact that you see me as a client. I will anonymously use information concerning you for purposes of research, teaching, public lecture, or publication with your written consent. I understand and agree to the above statement (Optional) I allow my history and charting information to be used anonymously for research, teaching, public lecture, or publication. CAPTCHA Code:*