1. How old are you? Select your age *

<35

35-40

40-45

45-50

>50

2. My periods are… *

Regular, every month, no change

Regular but shorter in length

Irregular - within the last year

Irregular - for more than 12 months

I am not sure, I have had my uterus removed but I still have my ovaries

I have not had a period in over a year or I have had both of my ovaries removed

3. I am experiencing hot flashes or night sweats *

Often

Sometimes

Never

4. I have trouble falling asleep or staying asleep *

Often

Sometimes

Never

5. With regard to my weight... *

I am gaining weight especially around my midsection (aka love handles)

I can't seem to lose weight

My weight isn't fluctuating

I'm having trouble keeping weight on.

6. I have noticed the following changes in my mood (check all that apply) *

Increased Anxiety or depression

Irritability or mood swings

Brain fog (inability to thinks clearly or concentrate)

No mood changes

7. I have noticed changes in my memory *

Often

Sometimes

Never

8.  My sex drive has... *

Stayed the same

Increased

Decreased

9. I experience vaginal dryness or pain during sex *

Yes

No

 10. I have noticed the following unexplained changes in my body (check all that apply) *

Fatigue or decreased energy

Joint pain

Dry itchy skin

Hair loss or thinning

Dizziness

Sensation of heart racing or skipping a beat

I have not experienced any of these symptoms

Full Name *

Email *

Phone

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