Are your periods ever more then 35 days or are they irregular? *

Yes

No

Do you feel a bit too feisty sometimes? *

Yes

No

Is most of your weight in your stomach? *

Yes

No

Do you have hair thinning on your head? *

Yes

No

Do you have excessive hair in places you don’t want it? *

Yes

No

Do you gain weight when you exercise? *

Yes

No

Do you ever feel like your cravings are intense? *

Yes

No

Do you grind your teeth or clench your fists? *

Yes

No

Do you have bloat? *

Yes

No

Do you have constipation *

Yes

No

Do you have loose stools? *

Yes

No

First Name

Last Name *

Email *

Phone *

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