KARRI JINKINS, AYURVEDIC HEALTH COUNSELOR, YOGA TEACHER
9172157710 * www.karrijinkins.com

Women's Intake

Name:

Current Age:

Age when menses started:

Age when menopause started:

(if applicable, circle all that apply if currently experiencing menopause symtoms.)
hot flashesvaginal drynessloss of sex drivenight sweatslow energymood swingspoor memory

Date of last menstrual cycle

Average length of cycle:

Average days of flow:

PMS (circle all that apply)
sore breastsbloatedfatiguecravingsemotionalcramping
Other:

Menstruation (circle all that apply)
crampingbloatedfatiguecravingsemotionalheadachesclotsspottingdigestion issues
Other:

Are you periods (circle all that apply)
heavylightpainfulirregular

Color of menstrual blood (circle all that apply). If fluctuate, mark all that apply.
pale/light redredbright reddark reddark red/brown

Have you been diagnosed with any of the following (circle all that apply)
endometriosisPCOSPIDinfertilityprolapseUTI
Other:

# of pregnancies:

# of children:

# of miscarriages/abortions:

Reproductive health
surgeriesbirth controlHRTNHRT/progesterone creamprolapseUTIImmediate family member with breast, uterine or ovarian cancerFibroid tumors or ovarian cystsAbnormal Pap

Date of last Pap test

Client’s Signature (Or Parental Representative):

Date:

Client’s Email: