Perimenopause / Menopause Questionnaire
Thanks for taking 5 minutes to complete this questionnaire. Just so you know, I'm a middle-age woman riding the wave of perimenopause and want to know more about your experience during this "magical" time in life! You can learn more about me at jenniferbrennanwellness.com. Again, thanks for sharing your input!
Are you in perimenopause (the years leading up to menopause as defined by the medical community) or menopause (menopause being defined as having NO menstrual cycle for at least 12 months)?
Perimenopause
Menopause
I'm not sure!
This question is for those in PERIMENOPAUSE. Please indicate if you have any of the following symptoms or experiences:
irregular periods (skipping cycles, cycles closer together)
heavier or lighter than normal periods
sleep disturbances
irritability
depression
anxiety
mood swings
panic attacks
weight gain
hot flashes during day
night sweats
vacillating from hot to cold
acne / skin disturbances
vaginal dryness
loss of libido
discomfort with sex
brain fog / trouble concentrating
This question is for those in MENOPAUSE. Please indicate if you have any of the following symptoms or experiences:
sleep disturbances
irritability
depression
anxiety
mood swings
panic attacks
weight gain
hot flashes during day
night sweats
vacillating from hot to cold
acne / skin disturbances
vaginal dryness
loss of libido
discomfort with sex
brain fog / trouble concentrating
What else would you like to share about your PERIMENOPAUSE or MENOPAUSE symptoms or experiences that may not have been mentioned above?
Indicate which, if any, of the following medicinal supports you take regularly.
Hormone replacement therapy (HRT)
Birth control pills
Antidepressant medication
Antianxiety medication
Herbal supplements / teas / tinctures
Other
Indicate which, if any, of the following non-medicinal supports you use regularly.
Massage therapy
Psychotherapy / talk therapy
Acupuncture
Support group
Coaching
Other
How easy is it for you to locate reputable information and support about perimenopause and menopause?
Easy!
Depends on the day.
Rarely; I struggle to find any good support or information
Never.
I don't look.
Do you feel lost and alone on your own perimenopause / menopause journey?
Yes, all the time.
Sometimes.
Never.
What is your biggest perimenopause / menopause struggle?
If you could wax poetic about perimenopause or menopause, what would you say? (Let it fly! Use YOUR words and your experience. Cursing is ok!)
Do you drink alcohol?
Yes, daily.
Yes, socially.
No, never.
What do you do to relax or unwind?
How often do you exercise or move your body?
Not All Often
1
2
3
4
5
6
7
8
9
Extremely Often
10
1 is Not All Often, 10 is Extremely Often
If you had your way, what kind of support would YOU like to receive during perimenopause / menopause?
*
A support group with monthly meetings.
Yoga classes specifically for those in perimenopause / menopause.
A group coaching program for community support, education, connection, personal growth.
1:1 coaching for support, education, connection, personal growth.
None, I prefer to fly solo.
Other
Name or initials
First Name
Last Name
Please share your email address (I'll only contact you if I have follow-up questions about your responses).
example@example.com
Your age
Submit
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