Harmonize your Hormone Questionnaire
I LOVE that you are here. This means you have some curiosity in the complexity of being a girl, hormones, and periods, and how you can learn about them to optimize your health. I can't wait to help you see if learning more can benefit you too! *****P.S. - all information will be kept confidential between you and me only!
Name
*
First name
Email
*
example@example.com
Age
*
Please Select
under 18
18-25
26-34
35-44
44-50
50+
What are your current health goals?
*
Do you have a "regular" period? (i.e. around same time and length each month)
*
Yes
No
I'm not sure
What PMS symptoms do you normally experience? (click all that apply)
*
Cramps
Moodiness
Headaches
Back pain
Breast tenderness
Constipation or diarreha
Bloating
Cravings
Fatigue
Acne
Sleep issues
Other
Are you currently on hormonal birth control?
*
Yes
No
I don't know
Prefer not to answer
Have you been previously diagnosed by a doctor with any hormonal or menstrual issues?
*
Yes
No
I don't know
Prefer not to answer
Click all that apply to the statement... "I am frustrated because...."
*
I feel like I do all the things and still can't loose weight or get the results I want
My energy is constantly low
I feel blah more days than I feel good
Many doctors say I am fine when I don't feel fine
I've hit a plateau
I want to make changes, but don't feel like I have time or energy for the work needed
Tell me a little about your experience with workouts and nutrition, and your mindset around it.
*
How much sleep do you get each night on average?
*
How much protein do you get in each day on average? (A good guess or saying I don't know is okay!)
*
How much water do you drink each day on average?
*
Please rate your interest in learning more about syncing your workouts, nutrition, and to do list with your cycle
*
1
2
3
4
5
6
7
8
9
10
In what country do you currently reside?
Please Select
United States
Canada
UK
France
Other
By clicking I agree below, you agree to receiving an email from me to discuss your answers and to chat about if learning how to harmonize your lifestyle habits and hormones is right for you. You are also agreeing to a bi-monthly email with tips and knowledge about hormones and can unsubscribe at anytime.
*
I agree
Submit
Should be Empty: