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Name*
Email*

1. My periods are irregular*
- Never
- Sometimes
- Always
2. I have hot flashes or night sweats*
- Never
- Sometimes
- Always
3. I have PMS symptoms*
- Never
- Sometimes
- Always
4. I have sleep difficulties*
- Never
- Sometimes
- Always

5. I feel tired, weak or even exhausted*
- Never
- Sometimes
- Always
6. I feel sad, moody or overwhelmed*
- Never
- Sometimes
- Always
7. I feel anxious and even have anxiety attacks*
- Never
- Sometimes
- Always
8. I'm forgetful, fuzzy-minded or confused*
- Never
- Sometimes
- Always

9. I'm irritable or out-of-sorts*
- Never
- Sometimes
- Always
10. I have digestive problems*
- Never
- Sometimes
- Always
(bloating, gas, diarrhea, constipation, nausea or heartburn)
11. I suffer from stiffness or achy joints*
- Never
- Sometimes
- Always
12. I struggle to lose weight or keep it off*
- Never
- Sometimes
- Always

13. My libido and sexual desire are low*
- Never
- Sometimes
- Always
14. I suffer from vaginal dryness*
- Never
- Sometimes
- Always
15. I crave sweets or carbohydrates, especially when I'm tired*
- Never
- Sometimes
- Always
16. My hair is clearly thinning*
- Never
- Sometimes
- Always

17. Are you being treated for any disease or serious health condition?*
- Yes
- No
18. Have you been diagnosed with osteopenia or osteoporosis?*
- Yes
- No
19. Have you suffered from a hormonal imbalance in the past?*
- Yes
- No
(thyroid condition, PCOS, insulin resistance, diabetes?)

20. Is work a source of stress for you?*
- Yes
- No
21. Do you feel overscheduled and rushed?*
- Yes
- No
22. Do you skip meals, frequently diet, or mostly eat out?*
- Yes
- No
23. Are your relationships a source of conflict or stress?*
- Yes
- No

24. Do you have caffeine or soft drinks more than once a day?*
- Yes
- No
25. Are you taking multiple prescriptions, or often use antibiotics?*
- Yes
- No
26. Do you have concerns about your family health history?*
- Yes
- No
27. Have you suffered a major emotional trauma recently?*
- Yes
- No
(such as divorce, separation, job loss, death of a loved one)

28. Do you eat protein at every meal?*
- Yes
- No
29. Do you eat fruits & vegetables every day?*
- Yes
- No
30. Do you eat breakfast every day?*
- Yes
- No
31. Are carbohydrates and/or sweets a big part of your diet?*
- Yes
- No
(count pasta too!)

32. Do you exercise four or more times a week?*
- Yes
- No
33. Do you get 7-8 hours of sleep per night?*
- Yes
- No
34. Do you practice some form of stress reduction?*
- Yes
- No
(such as meditation or yoga)

36. Are you on HRT or trying to get off it?*
- Yes
- No
37. Have you had a hysterectomy?*
- Yes
- No
38. Are you taking some form of prescription birth control?*
- Yes
- No
39. What’s your age?*

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