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Ursula Crane, CNM | Integrative & Functional Medicine for Women in Midlife Comprehensive Intake Form

How to Complete This Form

You may find that completing this form brings up reflections or memories about your health over the years — that’s completely normal and often very useful. Take your time. Most women spend about 45 minutes to an hour filling it out, sometimes in multiple sittings. Don't worry, you can pause and return to it whenever you need to.

Please answer as openly as you can. This is a judgment-free space — my role is to listen, interpret, and support, not to critique. The more I am able to understand what life really looks like for you, the more effective and practical your care will be.

Your information is kept strictly confidential and reviewed only by myself for the purpose of your consultation and follow-up care.

Take a breath, make a cup of tea, and start when you’re ready. This is the first step in building a clear, compassionate understanding of your health — and in helping you feel truly well again.