Full Name *

Email *

Phone *

Insurance

Please type your health insurance company

Member ID

Please type your health insurance member ID

Group ID

Please type your health insurance group ID

Please describe any hot flashes, sweating (episodes of sweating) that you have experienced: *

None

Mild

Moderate

Severe

Extremely Severe

Please describe any heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness) *

None

Mild

Moderate

Severe

Extremely Severe

Please describe any sleep problems (difficulty in falling asleep, difficulty in sleeping through the night, waking up early: *

None

Mild

Moderate

Severe

Extremely Severe

Please describe any depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings): *

None

Mild

Moderate

Severe

Extremely Severe

Please describe any irritability (feeling nervous, inner tension, feeling aggressive): *

None

Mild

Moderate

Severe

Extremely Severe

Please describe any anxiety (inner restlessness, feeling panicky): *

None

Mild

Moderate

Severe

Extremely Severe

Please describe any physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness) *

None

Mild

Moderate

Severe

Extremely Severe

Please describe any sexual problems (change in sexual desire, in sexual activity and satisfaction): *

None

Mild

Moderate

Severe

Extremely Severe

Please describe any bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence): *

None

Mild

Moderate

Severe

Extremely Severe

Please describe any dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse): *

None

Mild

Moderate

Severe

Extremely Severe

Please describe any joint and muscular discomfort (pain in the joints, rheumatoid complaints): *

None

Mild

Moderate

Severe

Extremely Severe

Please share any additional comments about your symptoms you would like to address:

Do you have cold hands and feet? *

Yes

No

Do you have daily bowel movements? *

Yes

No

Do you have gas, bloating or abdominal pain after eating? *

Yes

No

Please select your WEEKLY Activity Level based on this criteria: *

Physical activity that accelerates heart rate / breathlessness

0-1 day per week (Low)

2-3 days per week (Average)

More than 3 days per week (High)