Ovēa

Client Intake Form — Confidential

8 sections

Ovēa · Private Client Intake

Before we meet,
tell me everything.

There are no wrong answers here. The more detail you provide, the more useful our time together — and the more specific your 90-day protocol will be. Take the time you need. This form is entirely confidential.

Clarity Consult — $197

Strategy Session — $397

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Please allow up to 48 hours for a response before your scheduled session.

The basics

About You

First name *

Last name *

Email address *

Phone number (optional)

Date of birth *

State / Province

How did you hear about Ovēa?

Are you currently an active Ovēa member?

Yes — active member No — new client

Menstrual health

Your Cycle

If you are post-menopausal or have had a hysterectomy, answer what applies and note your status in the text fields. Skip questions that are not relevant.

Date of your last menstrual period (LMP)

Average cycle length

How long does your period typically last?

How would you describe your flow?

Cycle characteristics

Which of the following do you experience? (select all that apply)

Spotting before periodDays of brown/pink spotting before full flow begins Mid-cycle spotting or bleedingSpotting around ovulation or between periods Painful periodsCramping that disrupts daily life or requires medication Pelvic pain outside of periodPain that occurs mid-cycle, during ovulation, or at other times Pain during intercoursePelvic pain during or after sex Clots in flowClots larger than a quarter, or any clots routinely Absent periods (amenorrhea)No period without hormonal support for 3+ months None of the aboveMy cycle is regular and largely symptom-free

Are you currently using any hormonal contraception?

Yes No Recently stopped (within 12 months)

Which type, and for how long?

How long have you used / did you use it?

What's happening in your body

Current Symptoms

What is the primary reason you are seeking this consultation? *

Symptoms checklist — select all that currently apply

Hormonal & cycle-related symptoms

Irregular or absent cycles Severe PMS or PMDD Mood changes in the week before period Breast tenderness or swelling Cyclical bloating or water retention Heavy, prolonged, or painful periods

Androgen / skin / hair symptoms

Jawline or chin acne (hormonal pattern) Chest or back acne Scalp hair thinning or excess shedding Unwanted facial or body hair growth Oily skin or scalp Darkening of skin in skin folds or neck

Metabolic & energy symptoms

Unexplained weight gain — especially abdominal Difficulty losing weight despite lifestyle changes Persistent fatigue not resolved by sleep Energy crashes after meals Strong sugar or carbohydrate cravings Brain fog, poor concentration, or memory issues

Thyroid & adrenal symptoms

Always cold — hands, feet, or body temperature Heat intolerance or excessive sweating Hair loss including eyebrow thinning Heart palpitations or racing heart Anxiety — persistent or worsening Difficulty falling or staying asleep

Pelvic & reproductive symptoms

Pelvic pressure or feeling of fullness Urinary frequency or urgency Bowel changes tied to cycle — diarrhea or constipation Pain during or after intercourse Ovarian or side pain — sharp, dull, or pressure Vaginal dryness or discomfort

Perimenopause & menopausal symptoms

Hot flushes or night sweats Sleep disruption — waking between 2–4am Mood changes, irritability, or low mood Changing cycle length or skipped periods Joint or muscle aches None of the above — not relevant to me

How long have your primary symptoms been present? *

On a scale of 1–10, how significantly are your symptoms affecting your daily life?

1 — Minimal impact10 — Severely affecting daily function

Clinical pattern recognition

Hormone Assessment

This section helps me identify whether your symptom pattern reflects a hormonal root cause — and if so, which driver is most likely active. There are no right or wrong answers. Answer based on what you actually experience, not what you think your answer should be.

Estrogen pattern

Do you experience the following estrogen-dominance pattern? (select all that apply)

Heavy, prolonged, or painful periods Breast tenderness — especially in the 2 weeks before your period Significant bloating or fluid retention before period Stubborn weight gain around hips and thighs Premenstrual mood swings, irritability, or weeping None of the above

Progesterone pattern

Do you experience the following low-progesterone pattern? (select all that apply)

Short cycles — period arrives fewer than 25 days from start Brown spotting 2–7 days before period begins Anxiety or insomnia that worsens in the 2 weeks before your period Difficulty conceiving or history of early pregnancy loss Low mood, tearfulness, or withdrawal before period None of the above

Androgen / insulin-resistance pattern

Do you experience the following androgen or metabolic pattern? (select all that apply)

Persistent hormonal acne — jawline, chin, or neck Unwanted facial hair — upper lip, chin, sideburns Scalp hair thinning at the crown or temples Energy crashes and cravings — especially after carb-heavy meals Belly-predominant weight that is difficult to shift Irregular cycles — varying by more than 7 days month to month Skin tags at neck, armpits, or skin folds None of the above

PCOS / PMOS screening

PMOS (polycystic morphology of the ovaries on scan) refers to the imaging appearance of polycystic ovaries — present in up to 20–30% of women — without the additional criteria required for a PCOS diagnosis. Understanding whether you have the imaging pattern, the hormonal pattern, or both is critical to building the right protocol.

Have you ever been told your ovaries appear "polycystic" or show "polycystic morphology" on imaging?

Yes — and I have a PCOS diagnosis Yes — on imaging but no formal diagnosis No I'm not sure — I haven't seen the report

Do you have 2 or more of the Rotterdam Criteria for PCOS? (irregular/absent ovulation; clinical or lab androgen excess; polycystic ovarian morphology on ultrasound)

Yes — 2 or more criteria Only one criterion No Unsure / never been assessed

Recent lab work

Have you had any hormonal bloodwork in the past 12 months? (select all that apply)

Estradiol (E2) Progesterone (day 21 or timed) Total & free testosterone DHEA-S AMH (Anti-Müllerian Hormone) Thyroid panel (TSH, Free T3, Free T4, TPO antibodies) Fasting insulin or glucose / HbA1c FSH / LH No recent hormonal bloodwork

Any abnormal results you were told about? (or paste values if you have them)

Diagnoses, imaging, and prior care

Medical History

Have you been given any of the following diagnoses? (select all that apply)

PCOS — Polycystic Ovarian Syndrome PMOS — Polycystic Morphology on Scan (imaging only, no formal PCOS dx) Endometriosis Adenomyosis Uterine fibroids Ovarian cysts Diminished ovarian reserve (low AMH or AFC) Hypothyroidism or Hashimoto's thyroiditis Hyperthyroidism or Graves' disease Insulin resistance or pre-diabetes Premature ovarian insufficiency (POI) Unexplained infertility Pelvic floor dysfunction No formal diagnosis — I am still seeking answers

Prior imaging

Have you had a pelvic ultrasound in the past 3 years?

Yes — within the past 12 months Yes — 1–3 years ago No I'm not sure

What were you told? (copy the wording from your report if you have it)

Will you be submitting imaging for review? (for Clarity Consult or prior to a Strategy Session)

Yes — I have imaging to submit I only have the written report, not the images No imaging available to submit

Prior treatment & specialist care

Have you seen a specialist for any of your current symptoms?

OB/GYN Reproductive endocrinologist (RE / fertility specialist) Endocrinologist Naturopath or functional medicine practitioner Registered Dietitian or nutritionist GP / primary care only I have not seen a specialist yet

What treatments have you tried for your current symptoms? (select all that apply)

Hormonal contraception (prescribed for symptom management) Metformin or other insulin-sensitising medication Thyroid medication (levothyroxine, NDT, etc.) Hormone replacement therapy (HRT or BHRT) Surgical procedure — laparoscopy, myomectomy, ablation, etc. Self-prescribed supplements (inositol, vitex, DIM, etc.) Dietary changes specifically for symptoms Nothing yet — I haven't begun treatment

What, if anything, has helped — even partially?

What has definitely not helped — or made things worse?

Day-to-day context

Lifestyle & Habits

Current medications & supplementation

List all current prescription medications

List all current supplements, herbs, or OTC vitamins

Any known allergies or contraindications I should be aware of?

Nutrition

How would you describe your current eating pattern?

How many caffeinated drinks do you consume per day on average?

How often do you consume alcohol?

Movement & exercise

How often do you exercise per week?

What type of exercise do you primarily do?

Walking Strength / weight training HIIT or intense cardio Yoga or Pilates Running Cycling or spinning

Sleep & stress

How many hours of sleep do you typically get per night?

How would you rate your overall sleep quality?

1 — Very poor10 — Excellent

How would you rate your current stress level on a typical day?

1 — Very low10 — Extremely high / overwhelmed

What does your primary source of stress look like? (select all that apply)

Work demands or career pressure Caregiving — children, parents, family members Relationship or partnership stress Financial pressure Health-related anxiety or the diagnosis process itself Fertility or conception journey

Reproductive & obstetric history

OB & Fertility

This section is entirely optional for clients whose primary concern is not fertility or obstetric. If fertility or pregnancy is not relevant to your consultation goal, you may skip to Section 08. If it is relevant — even partially — please complete as fully as you are comfortable.

Which of the following reflects your current situation? (select all that apply)

Trying to conceive naturallyActively trying without assistance Trying to conceive after pregnancy lossAfter miscarriage, stillbirth, or TFMR Preparing for or undergoing IUIIntrauterine insemination Preparing for IVFPre-stimulation or prior to first retrieval Currently undergoing IVFIn stimulation or between retrievals IVF that did not succeedOne or more failed retrievals or transfers Egg freezing or fertility preservationElective or medical preservation Currently pregnantIncluding high-risk or medically complex pregnancy History of high-risk pregnancyPrevious preterm birth, preeclampsia, fetal growth restriction, etc. Fertility planning — not actively trying yetWanting to understand baseline before beginning Not relevant to my consultationFertility and OB are not my primary concern

Pregnancy history

Number of pregnancies

Live births

Pregnancy losses

If you have experienced pregnancy loss — please share only what you are comfortable with

This information helps me understand the full clinical picture — particularly for women TTC after recurrent loss, where imaging findings can sometimes offer clues that weren't investigated.

Fertility imaging & testing

Have you had any of the following fertility-specific tests? (select all that apply)

Antral Follicle Count (AFC)Ultrasound count of resting follicles, typically done days 2–5 AMH (Anti-Müllerian Hormone)Bloodwork marker of ovarian reserve HSG (Hysterosalpingogram)Tube patency X-ray test Saline infusion sonogram (SIS)Uterine cavity ultrasound evaluation Partner semen analysis Genetic testingCarrier screening, karyotype, or PGT on embryos None yet

Do you have AFC or AMH results to share? (if known)

How long have you been trying to conceive? (if applicable)

Is there anything else about your OB or fertility history that feels important for me to know before our session?

Your priorities & intentions

Goals & Main Concerns

What is your single most important goal for this consultation? *

What are your top 3 concerns right now? (listed in order of priority if possible)

What does success look like for you in 90 days? *

Is there a specific decision you are currently facing that you need support navigating?

Have you felt dismissed, disbelieved, or under-investigated by a previous provider?

Yes No In some ways, yes

Is there anything you want me to know that this form hasn't asked?

Where are you in your health journey right now? (select one)

Just beginning — I'm still trying to understand what's happening In the middle — I have some answers but not the full picture Ready to act — I understand my diagnosis and I want a real plan At a crossroads — I'm facing a significant decision and need guidance Tried things — none of it has worked and I need a different approach

I confirm that the information I have provided is accurate to the best of my knowledge. I understand that this consultation is for educational purposes only and does not constitute medical advice, diagnosis, or treatment. I will consult a licensed healthcare provider for any medical decisions. I have read and agree to the Privacy Policy and Terms of Use.

Please complete the required fields marked * and tick the confirmation box above.

Your form is encrypted and delivered securely to Hannah. You will receive a confirmation email within a few minutes of submission. Please allow up to 48 hours for a response before your scheduled session.

Confidentiality notice: All information submitted through this form is confidential and used solely to prepare for your Ovēa consultation. It is never shared with third parties. This form is for educational consultation purposes only. Ovēa is not a clinical practice and does not provide medical diagnosis or treatment. © 2026 Ovēa · helloovea.com

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Before we meet,tell me everything.

Thank you.Your intake form is in.

Before we meet,
tell me everything.

Thank you.
Your intake form is in.