Personal DetailsName First Last Email Enter Email Confirm Email Mobile Telephone NumberAddress Street Address Address Line 2 City County Post Code OptionalDate of Birth DD slash MM slash YYYY AgeHeightPlease complete in Feet and InchesFeetInchesMenopause StageWhich stage best describes you right now?PerimenopausalMenopausalPost-menopausalUnsureHealth & MedicationAre you currently taking any medication or supplements? Yes No if yes, please list (including HRT, supplements, or other medication)Please list (including HRT, supplements, or other medication)Do you have any medical conditions that may affect your wellbeing or coaching? Yes No OptionalPlease list any medical conditions that may affect your wellbeing or coachingSymptoms & WellbeingWhich symptoms are you experiencing? Hot flushes Night sweats Poor sleep Anxiety Low mood Brain fog Fatigue Weight changes Low confidence Low libido Joint aches Irregular periods Other (please specify) Tick all that applyPlease list additional symptomsWhich symptoms are impacting you the most right now?Lifestyle & SupportHow would you describe your current energy levels?Very lowLowModerateGoodHow supported do you currently feel with your menopause journey?Not supported at allVery supportedCoaching GoalsWhat prompted you to join BeeChanged at this time?What would you most like to achieve from the initial 4-week coaching programme?If coaching was successful, how would you like to feel at the end of the 4 weeks?Would you like ongoing support after the initial programme?A further 4-week block (£99)Weekly £30 per sessionNot currentlyIs there anything else you’d like me to know before we begin?Purchase 4 SessionsClick the button below to pay for your Sessions before finishing this form. Alternatively click here to payPay Here Purchase 1 SessionClick the button below to pay for your Session before finishing this form. Alternatively click here to payPay Here
