Please take your time to read over and complete this form before your first appointment.

You will also receive a copy via email for your records.

Please note: There are some simple self-tests involved that you’ll need to plan ahead to do, so make sure you read the questionnaire fully first and give yourself 3-4 days to complete it all properly.

Thank you

WOMEN – Menstruating
WOMEN – Perimenopausal / Menopausal
Childhood and family history
Your habits

Basal Temperature and Pulse Self-Test:
Record your temperature and pulse at the specified times, over three consecutive days.
Take first temp and pulse for day on waking, before getting up or drinking or eating anything.
With a digital or mercury thermometer, take your temperature (under the tongue with mouth closed). Please record your temperature in Celsius thank you. When taking pulse, make sure you’re in a rested state: count pulse at your inner wrist or neck over a 15 second period then multiply by 4

Your usual food intake: Give 2 examples of each meal that best represents your ‘usual’ eating

ADDITIONAL DRINKS your average number of daily glasses/cups of each of the following:

Your tastes

Your main aims: What do you really want to get out of this?!