Moonah Health Form

1
First, let’s make sure we have a menopause expert in your area:* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
First, let’s make sure we have licensed providers in your state:
2
Name* This field is required.
First Name
Last Name
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Email
example@example.com
5
Are you currently experiencing any of the following menopause symptoms? (Please check all that apply)* This field is required.
Hot flashes
Mood swings
Night sweats
Vaginal dryness
Insomnia
Other
6
How long have you been experiencing these symptoms?
Please Select
Please Select
Less than 6 months
6 months to 1 year
1 to 2 years
More than 2 years
7
On a scale of 1 to 10, how severe are your symptoms? (1 being very mild and 10 being very severe)* This field is required.
8
Are you currently taking any medications for menopause symptoms or other health conditions?* This field is required.
YESNO
9
Do you have any allergies, particularly to medications?
YESNO
10
Do you agree to securely share this information with our medical team to match you with the right specialist?
YESNO
Should be Empty: