Healthy Mantra
www.healthy-mantra.com
Menopause Symptom Quiz
Please complete the questions below to receive free resources related to your menopause symptoms
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Age
1. Have you experienced any irregular menstrual cycles recently?
Please Select
Yes
No
My periods have stopped completely
2. Do you experience hot flashes or night sweats?
Please Select
Frequently
Occasionally
Rarely or not at all
3. Do you often experience fatigue or lack of energy?
Please Select
Frequently
Occasionally
Rarely or not all
4. Have you noticed any changes in your sleep patterns, such as difficulty falling asleep or staying asleep?
Please Select
Frequently
Occasionally
Rarely or not at all
5. How would you rate the quality of your sleep?
Please Select
Poor
Fair
Good
6. Have you noticed any changes in your mood, such as increased irritability or mood swings?
Please Select
Frequently
Occasionally
Rarely or not at all
7. Have you experienced increased feelings of anxiety?
Please Select
Frequently
Occasionally
Rarely or not at all
8. Have you experienced symptoms of depression such as persistent sadness, hopelessness, or loss of interest in activities?
Please Select
Frequently
Occasionally
Rarely or not at all
9. Have you experienced any memory lapses or difficulty concentrating?
Please Select
Frequently
Occasionally
Rarely or not at all
10. Do you experience heart palpitations or a rapid heartbeat?
Please Select
Frequently
Occasionally
Rarely, not at all
11. Have you experienced itchy skin or skin irritation?
Please Select
Frequently
Occasionally
Rarely or not at all
12. Have you noticed any changes in your weight that you cannot explain through diet or exercise?
Please Select
Yes, I have gained weight
Yes, I have lost weight
No noticeable changes
13. Have you experienced any changes in libido (sex drive)?
Please Select
Yes, it has decreased
Yes, it has increased
No noticeable changes
14. Do you experience vaginal dryness or discomfort during intercourse?
Please Select
Frequently
Occasionally
Rarely or not at all
15. What are you most concerned about in terms of your menopause symptoms?
16. Is there anything you would like more information on?
Would you like to be added to our monthly newsletter to get more resources and information about menopause transition?
Please Select
Yes
No
Submit
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