Last Name

Email *

Menstrual Health

1. My periods are irregular: *

Never

Often

Always

2. I no longer have a period: *

Yes

No

Sleep & Energy

3. I have hot flashes or night sweats: *

Never

Often

Always

4. I have sleep difficulties: *

Never

Often

Always

5. I feel tired, weak, or exhausted: *

Never

Often

Always

Mood & Emotional Well-being

6. I feel sad, moody, or overwhelmed: *

Never

Often

Always

7. I feel anxious: *

Never

Often

Always

8. I'm forgetful and/or have brain fog: *

Never

Often

Always

9. I feel irritated and out-of-sorts: *

Never

Often

Always

Physical Health

10. I have digestive problems (bloating, gas, diarrhea, constipation, nausea, or heartburn): *

Never

Often

Always

11. I suffer from stiffness or achy joints: *

Never

Often

Always

12. I struggle to lose weight or keep it off: *

Never

Often

Always

Libido & Sexual Wellness

13. My libido and sexual desire are low: *

Never

Often

Always

14. I suffer from vaginal dryness: *

Never

Often

Always

Diet & Nutrition

15. I crave sweets or carbohydrates, especially when I'm tired: *

Never

Often

Always

16. Do you skip meals, frequently diet, or mostly eat out? *

Never

Often

Always

17. Do you have caffeine or soft drinks more than once a day? *

Never

Often

Always

18. Do you eat protein at every meal? *

Never

Often

Always

19. Do you eat fruits & vegetables every day? *

Never

Often

Always

20. Do you eat breakfast every day? *

Never

Often

Always

21. Are carbohydrates and/or sweets a big part of your diet? *

Never

Often

Always

Lifestyle & Mindset

22. Do you exercise four or more times a week? *

Never

Often

Always

23. Do you get 7-8 hours of sleep per night? *

Never

Often

Always

24. Do you feel overscheduled and rushed? *

Never

Often

Always

25. Do you practice some form of stress reduction? (such as meditation or yoga) *

Never

Often

Always

26. Do you have a positive mindset about my body: *

Never

Often

Always

27. Do you have a positive outlook on your future? *

Never

Often

Always