Menopause Wellness Form

Personal Information

Name

Age

Contact Number

City

Occupation

Emergency Contact

Menopause History

Are you currently perimenopausal or postmenopausal?

What symptoms are you experiencing (e.g., hot flashes, mood swings, weight gain, sleep issues)?

Are you undergoing any hormonal or other treatments?

Medical History

Do you have any chronic health conditions (e.g., osteoporosis, arthritis, hypertension)?

Have you had any recent surgeries or injuries?

Are you currently taking any medications or supplements?

Lifestyle and Wellness

What are your diet preferences (e.g., vegetarian, non-vegetarian, vegan, etc.)?

How would you rate your stress levels on a scale of 1 to 10?

What is your current exercise and activity level?

How would you describe your sleep quality?

Goals for Fertility Yoga

What are your primary goals for menopause yoga? (e.g., reducing symptoms, improving bone health, achieving mental relaxation, increasing flexibility, etc.)

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Menopause Wellness Form

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