Hormonal Health & Endocrine Disruptor Self-Assessment

Instructions:

Choose the answer that best reflects your current experience over the past 2 to 3 months.

How is your daily energy? *

A. Steady and strong most days

B. Mostly okay, with occasional dips

C. Often tired or sluggish

D. Frequently exhausted, even with rest

How would you describe your sleep? *

A. I sleep well and wake refreshed

B. Sleep is decent but not always restorative

C. I often wake tired or sleep lightly

D. I regularly struggle with falling asleep, staying asleep, or waking restored

For women: how would you describe your menstrual cycle? *

A. Regular and predictable

B. Mostly regular with minor changes

C. Irregular, heavier, lighter, or more symptomatic than I’d like

D. Very irregular, missing cycles, or severe PMS / period symptoms

NOT APPLICABLE

For men or women not cycling: choose based on overall hormonal rhythm, mood stability, and body consistency: *

A. Very stable

B. Mostly stable

C. Noticeable fluctuations

D. Significant fluctuations

NOT APPLICABLE

How often do you experience mood swings, irritability, anxiety, or feeling emotionally “off”? *

A. Rarely

B. Sometimes

C. Often

D. Very often

How often do you use plastic containers, plastic water bottles, or heat food in plastic? *

A. Rarely or never

B. A few times per week

C. Most days

D. Daily, including with heat

How often do you eat ready-made meals or take-away packaged foods/ restaurant food? *

A. Rarely

B. A few times per week

C. Once a day

D. More than once a day

How often are you exposed to synthetic fragrance from perfume, candles, air fresheners, laundry products, or body care? *

A. Rarely or never

B. Occasionally

C. Most days

D. Constantly throughout the day

What best describes your personal care and cleaning products? *

A. Mostly fragrance-free, low-tox, or simple ingredient products

B. A mix of cleaner and conventional products

C. Mostly conventional products

D. I use many scented conventional products daily

First Name *

Last Name

Email *

Phone *