ABOUT YOU
How old are you?
Under 35
35–39
40–44
45–49
50–54
55-59
60+
Which best describes your menstrual status?
Regular periods
Somewhat irregular
Very irregular
No periods for less than 12 months
No periods for more than 12 months
Hysterectomy
CORE MENOPAUSE SYMPTOMS
Do you experience hot flushes?
Never
Occasionally
Weekly
Several times per week
Daily
Do you experience night sweats?
Never
Occasionally
Weekly
Several times per week
Daily
Has your sleep quality changed?
No
Slightly
Moderately
Significantly
Severely
Have you noticed increased anxiety or worry?
No
Mild
Moderate
Significant
Severe
Have you experienced mood changes or irritability?
No
Mild
Moderate
Significant
Severe
Do you experience brain fog?
Never
Occasionally
Weekly
Frequently
Daily
Have you noticed memory or concentration problems?
No
Mild
Moderate
Significant
Severe
WEIGHT & METABOLIC HEALTH
Have you gained weight in the last 2 years?
No weight gain
1–3 kg
4–7 kg
8–12 kg
More than 12 kg
Has most of the weight accumulated around your abdomen?
No
Slightly
Moderately
Significantly
Very significantly
Are you finding it harder to lose weight than before?
No
Slightly
Moderately
Significantly
Extremely
How would you rate your energy levels?
Excellent
Good
Average
Poor
Very poor
SEXUAL & VAGINAL HEALTH
Have you noticed reduced libido?
No
Slightly
Moderately
Significantly
Severely
Do you experience vaginal dryness?
No
Occasionally
Moderate
Significant
Severe
Is intercourse uncomfortable or painful?
No
Occasionally
Sometimes
Frequently
Almost always
Have you experienced any of the following? (Select all that apply)
Urinary urgency
Bladder irritation
Pain or burning when passing urine (without an active infection)
Frequent urinary tract infections (UTIs)
Urine leakage (incontinence)
None of the above
LONG-TERM HEALTH
Do you have a family history of: (Select all that apply)
Breast cancer
Heart disease
Osteoporosis
Dementia
Diabetes
None
Have you ever used hormone therapy?
Currently
Previously
Never
Have you had any of the following? (Select all that apply)
Thyroid disorder
High cholesterol
High blood pressure
Diabetes
PCOS
None
IMPACT
How much are these symptoms affecting your quality of life? Scale 1–10
1–2
3–4
5–6
7–8
9–10
What would you most like to improve? Choose one:
Weight
Sleep
Energy
Brain Fog
Mood
Libido
Hot Flushes
Long-Term Health
INFO
First Name
Last Name
Phone
*
Email
*