Whole Human Wellness & Recovery

Client Intake & Blueprint Questionnaire

Whole-human intake for the Confidently Human app: metabolic health, hormones, stress, mindset, habits, support, and readiness for coaching modalities. Takes about 20–30 minutes. Save time by answering what you know and skipping what you don't.

I've been thinking about the person on the other side of this form, and I want to say something before you start filling it out.

There are no wrong answers here. This isn't a test and it isn't being graded. It's just how I get to know you before we ever sit down, so our first real conversation can start from a place of already understanding you a little.

Answer what you know, skip what you don't, and be as honest as you can. The more real this is, the more useful it is for both of us.

Wendy

Full Name

Date

Phone

Date of Birth

Occupation

How did you find us?

Metabolic Health

Your body’s current starting point: no judgment, just information.

Current weight (optional)

Height

Highest adult weight

What is your primary health goal right now?

Current diagnosed conditions (thyroid, PCOS, diabetes, insulin resistance, etc.)

Current medications and supplements (include dosage if known)

Are you currently using, or have you used, a GLP-1 or peptide medication?

Select one

Currently using

Used in the past

Actively exploring / talking to a provider

Not using and not currently interested

If currently using: which medication/protocol?

If yes above: what has that experience been like? What feels supported, and where do you feel like you’re on your own?

Past weight loss attempts: what have you tried, and what happened?

How would you rate your daily energy over the last month?

Running on empty

12345

Steady and strong

How would you rate your sleep quality?

Exhausted no matter what

12345

Wake up rested

Do any of these show up regularly for you?

Select all that apply

Bloating or digestive discomfort

Sugar or carb cravings

Afternoon energy crashes

Inflammation or joint pain

Frequent headaches

Skin changes (acne, dryness, rashes)

Cold hands and feet

Difficulty building or keeping muscle

Family health history worth knowing (heart disease, diabetes, thyroid conditions, cancer, etc.)

Any allergies or foods your body reacts to?

Hormones

Menstrual health, menopause, and the hormonal picture underneath everything else.

Which best describes where you are right now?

Select one

Regular menstrual cycle

Irregular cycle

Perimenopause

Postmenopausal

Currently pregnant or postpartum

On hormonal birth control

Not applicable / prefer not to say

Are you currently on hormone replacement therapy (HRT) or any hormone-related medication?

Do you experience any of the following?

Select all that apply

Hot flashes or night sweats

Significant mood swings tied to your cycle

PMS or PMDD symptoms

Low libido

Vaginal dryness or discomfort

Hair thinning or hair loss

Difficulty losing weight despite consistent effort

Have you had hormone labs done in the last 12 months? If so, what did you learn (or what do you remember)?

Anything else about your hormonal health you want me to know before we talk?

Stress & Nervous System

Your cravings and resistance are signals, not character flaws: this helps us read them.

How would you rate your day-to-day stress level?

Calm and regulated

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Constantly overwhelmed

What are the two or three biggest sources of stress in your life right now?

When you’re stressed, what does your body tend to do?

Select all that apply

Jaw clenching or teeth grinding

Tension in shoulders/neck/back

Headaches or migraines

Stomach or digestive upset

Racing heart or shallow breathing

Trouble falling or staying asleep

Shutting down / going numb

Snapping or feeling irritable

Under real pressure, which do you notice most in yourself?

Select one

Fight: I get reactive, snappy, or need to fix it immediately

Flight: I want to escape, stay busy, or avoid the situation

Freeze: I shut down, go blank, or can’t make a decision

Fawn: I people-please, over-apologize, or smooth things over

Honestly not sure

Have you ever gone through a period you’d describe as burnout?

What do you currently do to manage or release stress? (walking, therapy, journaling, exercise, nothing yet, etc.)

Is there anything from your past: an event, a season of life, a relationship: that still shows up in your body today? Share as much or as little as feels right.

Mindset & Identity

The beliefs underneath the behavior: this is where lasting change actually starts.

How confident do you feel in yourself day to day?

Not very

12345

Very confident

Finish this sentence: "I’ve always struggled with..."

What does your inner voice sound like when things go wrong: supportive, critical, something else?

What is a belief about yourself you’d love to let go of?

Who do you want to become on the other side of this work?

Have you worked with any of the following before?

Select all that apply

A therapist or counselor

A life or business coach

A nutritionist or dietitian

A personal trainer

None of the above

If yes to any above: what worked, and what didn’t?

How would you describe your current relationship with your body, in a sentence or two?

Habits & Daily Routine

The real, unfiltered version of your week: not the version you wish it was.

Walk me through a typical weekday, start to finish.

Usual bedtime

Usual wake time

Hours of sleep (avg)

Current movement / exercise habits

Select one

Little to no regular movement

Walking a few times a week

Structured workouts 1–2x/week

Structured workouts 3+ times/week

Movement feels inconsistent or all-or-nothing

How would you describe your eating patterns most days?

Select one

Structured meals, mostly consistent

Grazing / eating on the run

Skipping meals, then overeating later

Emotional or stress eating

Restricting, then rebounding

Feels pretty balanced overall

What does your relationship with food feel like right now, in your own words?

Water intake on a typical day (rough estimate is fine)

Do you have a morning or evening routine? What does it include?

Where does screen time (phone, TV, work) tend to eat into your day the most?

Support

Change doesn’t happen in isolation: who’s actually in your corner?

Who is currently in your support system?

Select all that apply

Partner/spouse

Close friends

Family

Coworkers

A coach or therapist

A faith or spiritual community

Honestly, not many people right now

How supported do you feel by the people around you in making changes like this?

Pretty much on my own

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Fully backed

Does anyone in your life actively support your health and growth goals? Who?

Does anyone in your life make this harder: even unintentionally?

How do you want to be supported by me and this program?

Select all that apply

Frequent check-ins

Accountability that’s firm but kind

Space to process, not just tasks

Straightforward information and a clear plan

Encouragement more than structure

A mix: I’ll let you know what I need as we go

Are you interested in connecting with other women in this program (group chat, community space)?

Select one

Yes, I’d love that

Maybe, depends on the group

I’d rather keep this 1:1

Openness to Modalities

There’s no right answer here: this just helps me meet you where you actually are.

Which of these have you personally tried before?

Select all that apply

Hypnosis

Meditation or breathwork

Energy healing (Reiki, Body Code, etc.)

Muscle testing / kinesiology

Somatic or nervous-system-focused bodywork

Journaling as a regular practice

Talk therapy

None of the above yet

How open are you to hypnosis as part of our work together?

Not for me

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Very curious / ready to try

How open are you to energy work or intuitive/felt-sense practices?

Skeptical

12345

Already believe in it

How open are you to somatic and nervous-system-based practices (vs. purely physical fitness)?

Prefer to just move my body

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Deeply interested

Is there anything spiritual, energetic, or mind-body related that has genuinely helped you before?

Is there anything in this category that feels uncomfortable, "woo," or not for you? No wrong answer: I’d rather know now.

When something feels stuck, what are you more drawn to first?

Select one

Talking it through

Feeling it out in my body

Taking practical action

A mix, depending on the day

Goals & Vision

Where this is all headed.

What made now the right time to start this?

If this work went really well, what would be different in six months?

What’s the biggest obstacle that’s gotten in your way before?

Is there anything you’re nervous to tell me, or haven’t told anyone else, that would actually be useful for me to know?

Agreements

Coaching with Confidently Human addresses the whole human: mindset, habits, nervous system, and behavioral infrastructure. It is not medical care and does not replace the guidance of your physician or prescribing provider. Any clinical decisions, lab interpretation, or prescription guidance are handled by a licensed provider, not by coaching.

I understand coaching is not a substitute for medical or mental health treatment, and I will continue working with my provider(s) as needed.

I consent to my information being used to personalize my coaching plan within Confidently Human.

I am open to being contacted about relevant programs, labs, or resources (you can opt out anytime).

I would be open to sharing a testimonial or before/after in the future (fully optional, asked again before anything is used).

Signature (type your full name)

Date

Thank you for trusting me with this. I'll read every word before we talk. Everything you share here is kept confidential and used only to personalize your care.