Get Started If you're ready to get started, you're in the right place! Let's get started with scheduling an appointment. (If you have a more general inquiry, please contact Georgie here instead). What type of appointment are we scheduling today?*Health & Lifestyle CoachingWeight lossHelp with MenopauseName* First Last What do you prefer to be called?Gender*FemaleMaleMailing address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Date of birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Type of work*Marital status*MarriedDomestic PartnerSingleDivorcedWidowedName of spouse or partner* First Last How did you hear about me?What is your level of commitment to your health and wellbeing?*Any previous surgeries? Any health related concerns/challenges?*List any recreational drugs, over the counter drugs, or prescription medication.*List any supplements or vitamins.*How does your condition interfere with work? Sleep? Your daily routine or activities?*Please describe your diet / nutrition / eating habits*What are your exercise habits? (What kind and how often)?*What is your daily water intake?*Family relationships (i.e. good, stressful, none...)*What's your satisfaction with work?*List the stresses in your life*Grade your physical health*Grade your mental / emotional health*Do you feel connected to your spiritual self?*If so, what does that mean for you?*If so, what does that mean for you?*What brings you Joy? Inspires You? Makes you feel better about yourself?*Any unhealthy habits?*Health conditionsPlease check each of the diseases or conditions your body is expressing or has expressed in the past. While they may seem unrelated to the purpose of this visit, they can affect the overall assessment and care plan. Severe or Frequent Headaches Sinus Problems Dizziness Loss of Sleep Pain Between the Shoulders Frequent Neck Pain Numbness/Pain in Arms/Hands Numbness/Pain in Legs/Feet Lower Back Problems Digestive Problems Ulcers/Colitis Heart Attack/Stroke Congenital Heart Defect Heart Surgery/Pacemaker Heart Murmur High/Low Blood Pressure Difficulty Breathing Asthma Arthritis Alcohol/Drug Abuse Venereal Disease HIV/AIDS Diabetes Tuberculosis Shingles Kidney Problems Hepatitis Cancer Chemotherapy Anemia Rheumatic Fever Psychiatric Issues Thyroid Issues Health & Lifestyle CoachingIn which areas of your life do you already feel successful?*In which areas of your life would you like to grow?*Which of these areas would you like to address first?*What is your goal for coaching sessions with Georgie?*Other information you think I should know.*Help with MenopauseAt what age did you begin to feel the affects of menopause?*What medications and or supplements are you taking for the symptoms of menopause?*What family experiences or beliefs do you have about menopause?*What will be different after you have gone through menopause?*What would you like your life to be like now?*Other information you think I should know.*CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.