Hot Flashes

Are you having or have experienced night sweats or hot flashes? *

Yes, frequently

Yes, sometimes

Irritability

Are you having or have experienced mood changes or irritability? *

Yes, frequently

Yes, sometimes

Vaginal

Are you having or have experienced vaginal dryness or painful sex? *

Yes, frequently

Yes, sometimes

Libido

Are you having or have experienced loss of interest in sex? *

Yes, mostly

Yes, somewhat

Bloating

Are you having or have experienced weight gain or bloating? *

Yes, a lot

Yes, a little

Weight Gain

Have you gained weight for no discernable reason? Where is your weight at today? Choose the number below that corresponds to where you currently are on the scale. *

I am more than one hundred pounds overweight

I have more than 75 pounds to lose

I am more than sixty pounds overweight

I have been diagnosed with obesity

I need to drop fifty pounds

I have thirty to forty pound to lose

I am twenty pounds overweight

I need to lose ten pounds

I could use to lose five pounds

I am at my ideal weight

Memory Loss

Are you having or have experienced memory loss or issues with mental clarity? *

Yes, frequently

Yes, sometimes

Sleep

Are you having or have experienced changes in sleeping habits, or sleeping poorly? *

Yes, basically nightly

Yes, sometimes

Hair

Are you having or have had hair loss or thinning of your hair? *

Yes, a lot

Yes, a little bit

Urinary Issues

Are you having or have experienced urinary urgency, frequency, or recurrent urinary tract infections? *

Yes, frequently

Yes, sometimes

Full Name *

Email *

Phone *

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