Full Name
*
Phone
Email
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Are you having or have experienced night sweats or hot flashes?
Yes
No
Maybe
Are you having or have experienced mood changes or irritability?
Yes
No
Maybe
Are you having or have experienced vaginal dryness or painful sex?
Yes
No
Maybe
Are you having or have experienced loss of interest in sex?
Yes
No
Maybe
Are you having or have experienced weight gain or bloating?
Yes
No
Maybe
Are you having or have experienced memory loss or issues with mental clarity?
Yes
No
Maybe
Are you having or have experienced changes in sleeping habits?
Yes
No
Maybe
Are you having or have had hair loss or thinning of your hair?
Yes
No
Maybe
Are you having or have experienced urinary urgency, frequency, or recurrent urinary tract infections?
Yes
No
Maybe
Do you have a family history of (check all the apply)?
Osteoporosis
Heart Disease
Diabetes
Breast Cancer