Menopause Quiz
Name
First Name
Last Name
Email
example@example.com
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Please answer the questions
1. Over the past month how would you rate your energy level?
*
I have full energy level all day
I have enough energy for most part
I have energy only some of the time
I struggle with low energy most of the day
2. How are you doing with your weight?
*
I am less than 10 pounds overweight
I am about 10 pounds overweight
I am 11-20 pounds overweight
I am over 20 pounds overweight
3. How well are you sleeping?
*
I fall asleep quickly and stay asleep all night
I have problem falling asleep or staying asleep once in a while
Some nights I have trouble falling or staying asleep
Most nights I have trouble falling or staying asleep
4. How’s your mood over the past month or two?
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I feel happy most of the time
Pretty good most of the time
Low or moody some of the time
Low most of the time
5. How’s your concentration? Are you able to focus without distraction?
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Always
Most of the time
Some of the time
Rarely
6. How motivated you are compare to your 20s or 30s?
*
The same or higher
Somewhat lower
Noticeably lower
Not motivated at all
7. How is your sex drive?
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Amazing
Great for the most part
If needs be I do
None what so ever
8. Does it happen you walk in the room for a purpose but forget what that was?
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Never
Rarely
Sometimes
Almost daily
9. How would you rate you overall health?
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I consider myself a healthy person
I am really good apart from a few minor issues
My health is ok but could be better
I have lots of health issues
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