Menopause Experience Survey

1

Thank you so much for participating in this anecdotal menopause survey. Each of us experience menopause differently and we would love to hear your experiences (past or present) and any other information you wish to share and also your thoughts or experience with HRT (hormone replacement therapies).

Please Tick your symptoms and add any additional information.

For any questions/comments, please write to:

hello@zillacarina.com

PLEASE NOTE: THIS INFORMATION WILL NOT BE SHARED OTHER THAN IN STATISTICAL FORM.

All information collected is STRICTLY CONFIDENTIAL
2
3

Thank you so much for participating in this menopause survey. Each of us experience menopause differently and we would love to hear your experiences (past or present) and any other information you wish to share and also your thoughts/experience with HRT (hormone replacement therapies).

Please Tick your symptoms and add any additional information.

PLEASE NOTE: THIS INFORMATION WILL NOT BE SHARED OTHER THAN IN STATISTICAL FORM.

All information collected is STRICTLY CONFIDENTIAL
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Name* This field is required.
First Name
Last Name
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Age* This field is required.
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Menopause Symptoms* This field is required.Please tick all that apply
Hot Flashes/Night Sweats
Sleep Problems/Tiredness
Irregular Menstrual Cycles
Dry Vagina
Bladder Problems
Rapid Heart Rate or Palpitations
Memory/Concetration
Low Self Esteem
Mood Swings
Irritability
Anxiety/Panic Attacks
Brain Fog
Allergies
Bloating
Breast Pain/Tenderness
Depression
Dizziness
Burning Tongue
Hair Loss
Itchy Skin
Osteoporosis
Tingling Extremities
Weight Gain
HRT
Other
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Any questions or Comments?* This field is required.
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EmailPlease provide your email below if you would like to receive further communication
example@example.com
Should be Empty: