4‑Week Menopause Sleep Reset • Intake Form

4‑Week Menopause Sleep Reset — Intake

Please complete before your first session. You can download a PDF of your responses and email it to info@yoursleepclinic.com. This programme uses CBT‑I strategies adapted for menopause.

1) Your Details

Full name

Date of birth

Phone

GP / Primary care provider

How did you hear about us?

Consent

I consent to coaching, understand this is not medical care, and agree to data being used to deliver services and communicate with me.

2) Menopause Status & Hormones

Current stage

If applicable: date of last menstrual period

Current bleeding/spotting pattern

Gynaecological surgeries (e.g., hysterectomy, oophorectomy)

Are you using HRT?

If yes/past: type & route (e.g., transdermal estradiol + oral progesterone)

Current dose & schedule

Start date (or dates of previous trials)

Benefits or side‑effects noticed

Non‑HRT options (e.g., SSRI/SNRI, gabapentin, clonidine, herbal)

3) Symptom Snapshot (past 2 weeks)

Hot flushes frequency (per day)

Night sweats (nights/week)

Urogenital symptoms (dryness, UTIs)

Aches/pains or restless legs at night

Anxiety/low mood (0–10; higher = worse)

Brain fog (0–10)

4) Sleep Concerns (CBT‑I focus)

What’s most difficult right now? (e.g., getting to sleep, waking at 3am, early waking)

How long has sleep been problematic?

Initial trigger(s) if known

Top 3 goals for this programme

5) Typical Sleep Pattern (averages)

Usual bedtime (weeknights)

How long to fall asleep (minutes)

Number of awakenings

Total time awake during the night (minutes)

Final wake time

Out of bed time

Nap minutes per day (avg)

Total time in bed (hours)

Estimated total sleep time (hours)

Rough averages are fine — we’ll refine with a sleep diary if needed.

6) Health & Medications

Medical conditions (thyroid, migraines, cardiovascular, metabolic, etc.)

Medications & supplements (dose/time)

History relevant to HRT safety (e.g., VTE/clots, breast cancer, stroke, migraine with aura)

Height (cm) & weight (kg) if known

7) Lifestyle Factors

Caffeine (type & daily amount)

Alcohol (units/week)

Nicotine or vaping

Exercise (type & weekly minutes)

Late eating or spicy meals close to bedtime?

8) Sleep Environment & Behaviours

Share bed/room with partner or pets?

Screens in bed (mins before sleep)

Noise/light/temperature issues?

Cooling strategies used (fan, cooling pillow, layered bedding, moisture‑wicking PJs)

9) Quick Screening

Snore loudly?

Stops in breathing observed?

Sleepiness while driving?

Restless legs sensations that worsen at night?

Common flush triggers (alcohol, heat, stress, sugar, spicy foods)

10) Beliefs, Distress & Readiness

How much do you worry about sleep? (0–10)

How much control do you feel you have over sleep? (0–10)

Motivation to follow plan (0–10)

Likely barriers (e.g., shift work, caregiving, travel)

Submission & Download

When finished, click “Download my completed form (PDF)”. Then attach it to an email to info@yoursleepclinic.com.

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