Are
you struggling with Perimenopause, Menopause or Hormone Imbalance?
Name
*
Email
*
example@example.com
How did you come across me?
(ex: referred by name, FB, IG, etc)
What is your Instagram handle
What is your FB account name
Describe your current stage:
Perimenopause (2-12 years before menopause)
Menopause (no cycle for 365 consecutive days or more)
Not really sure - but I know or feel like something with my hormones are out of balance
What symptoms are you experiencing?
Painful intercourse (including vaginal dryness)
Low Libido
Night Sweats
Hot Flushes
Low energy / Fatigue
Osteoperosis
Excessive Sweating
Sleep Issues (waking from 2-4am, Insomnia)
Absence of Menstruation or Irregular Periods
Hair Dryness / Loss of hiar
Anxiety
Mood Swings / Irritability
Weight Change
Excessive Belly Fat / Thickness around the middle
Breast tenderness / size change
Depression
Panic Attacks
Brain Fog / Memory Problems
Joint Pain / Muscle Aches
Change of Taste
Body Odor
Acne
Skin Tags
Frequent Urination
PMS (getting worse)
Worst Case Scenario (impending doom)
Dizziness
Change in periods (heavier, or lighter/longer or shorter)
Other
If other, please describe
Who do you go to for answers to your health issues?
My general practitioner
Holistic Dr
Google
Nutritionist
Friend
Anyone that will help me!
Other
If other, please describe
Would you like to receive info on how to treat your symptoms naturally?
Yes
No
Would you like more info on Hormone Balancing?
Yes
No
More info on Hormone Balancing CLICK
HERE
If you are ready to get started on my Healthy Hormone Balancing Protocol, CLICK
HERE
Are there any other symptoms or concerns not represented above that you want help with?
List in detail all other concerns or symptoms you may be experiencing
Submit
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