Menopause Symptom Quiz

First Name

Last Name

Email *

Phone *

Are you experiencing HOT FLASHES? *

None

Mild

Moderate

Severe

Do you experience IRRITABILITY, ANXIETY, or MOOD CHANGES? *

None

Mild

Moderate

Severe

Do you experience changes in your MENSTRUAL CYCLE? *

None

Mild

Moderate

Severe

Do you experience SLEEP DISRUPTIONS or INSOMNIA? *

None

Mild

Moderate

Severe

Do you experience UNEXPLAINED ABDOMINAL WEIGHT GAIN? *

None

Mild

Moderate

Severe

Do you experience CHANGES IN YOUR SEXUAL DESIRE or LIBIDO? *

None

Mild

Moderate

Severe

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