AMIE Method – Personal Review Form
Fuel. Strengthen. Thrive.
Basic Information
Name: _______________________________
Date of Birth: ___________________________
Occupation: ___________________________
Phone Number: _________________________
Email Address: __________________________
Preferred Communication Method: __________________________
Current Life Snapshot
What brings you to the AMIE Method? What are you hoping to gain from this experience?
__________________________________________________________
Top 3 Goals (Physical, Emotional, Lifestyle):
__________________________________________________________
What challenges have made progress difficult in the past?
☐ Time ☐ Motivation ☐ Emotional Eating ☐ Hormones
☐ Injury/Pain ☐ Other: __________________________
Midlife Wellness & Hormonal Health
Current Stage:
☐ Perimenopause ☐ Menopause ☐ Postmenopause ☐ Not Sure ☐ N/A
Recent Symptoms (Check all that apply):
☐ Fatigue ☐ Weight Gain ☐ Mood Swings ☐ Poor Sleep
☐ Brain Fog ☐ Irregular Periods ☐ Hot Flashes ☐ Low Libido
☐ Joint Pain ☐ Headaches ☐ Migraines ☐ Other: _____________
Do you take HRT (Hormone Replacement Therapy)?
☐ Yes ☐ No ☐ Considering it
If yes, please list type and dosage (if known): _________________________
Have you had recent hormone or thyroid testing?
☐ Yes ☐ No
Findings (if any): ______________________________________________
Nutrition & Relationship with Food
Current Eating Habits:
☐ Structured ☐ All or Nothing ☐ Emotional Eating ☐ Grazing
☐ Restrictive ☐ Confused
What does a typical day of eating look like for you?
__________________________________________________________
Any dietary restrictions or preferences?
__________________________________________________________
Do you often feel:
☐ Full ☐ Hungry ☐ Cravings ☐ Afraid of Foods
What is your relationship with food?
__________________________________________________________
What is your relationship with your body?
__________________________________________________________
What brings you joy?
__________________________________________________________
Medications, Supplements & Family History
Are you currently taking any medications? Please list:
__________________________________________________________
Do you take any supplements or vitamins? Please list:
__________________________________________________________
Any family history of illnesses or chronic conditions?
__________________________________________________________
Movement & Physical Health
Current exercise routine (type and frequency):
__________________________________________________________
Any injuries or physical limitations?
__________________________________________________________
Movement priorities (check all that apply):
☐ Building Strength ☐ Improving Balance/Core ☐ Gaining Energy
☐ Losing Fat ☐ Flexibility ☐ Consistency
Mindset, Lifestyle & Stress
Current stress level (1 to 10): ______
Top sources of stress:
__________________________________________________________
Sleep Quality:
☐ Restful ☐ Trouble Falling Asleep ☐ Wake Often ☐ Wake Tired
Do you feel supported?
☐ Yes ☐ Somewhat ☐ No
Body Image & History
What was your relationship with your body growing up?
__________________________________________________________
What is your relationship with your body now?
__________________________________________________________
Vision for Thriving
What does thriving look like for you in this chapter of life?
__________________________________________________________
What do you want to feel more of (check all that apply):
☐ Energy ☐ Peace ☐ Strength ☐ Control
☐ Confidence ☐ Joy ☐ Connection
Is there anything else you’d like to share?
__________________________________________________________
Client Signature: ___________________________
Date: ___________________________
Thank you so much for sharing this with me and letting me be part of this next chapter in your life.