PeriMenopause Symptom Survey

1
Email Address* This field is required.Receive your results directly to your inbox.
example@example.com
2
Please indicate which of the following symptoms apply to you at this time.

Please mark ONE Box For EACH Symptom. For Symptoms That Do Not Apply, Please Mark “None”.
3
Hot flashes, sweating (episodes of sweating)* This field is required.
None
Mild
Moderate
Severe
Extremely Severe
4
Heart discomfort (unusual awareness of heartbeat, heart skipping, heart racing, tightness)* This field is required.
None
Mild
Moderate
Severe
Extremely Severe
5
Sleep problems (difficulty in falling asleep, difficulty in sleeping through the night, waking up early)* This field is required.
None
Mild
Moderate
Severe
Extremely Severe
6
Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)* This field is required.
None
Mild
Moderate
Severe
Extremely Severe
7
Irritability (feeling nervous, inner tension, feeling aggressive)* This field is required.
None
Mild
Moderate
Severe
Extremely Severe
8
Anxiety (inner restlessness, feeling panicky)* This field is required.
None
Mild
Moderate
Severe
Extremely Severe
9
Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)* This field is required.
None
Mild
Moderate
Severe
Extremely Severe
10
Sexual problems (change in sexual desire, in sexual activity and satisfaction)* This field is required.
None
Mild
Moderate
Severe
Extremely Severe
11
Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence)* This field is required.
None
Mild
Moderate
Severe
Extremely Severe
12
Dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse)* This field is required.
None
Mild
Moderate
Severe
Extremely Severe
13
Joint and muscular discomfort (pain in the joints, rheumatoid complaints)* This field is required.
None
Mild
Moderate
Severe
Extremely Severe
14
20. To what extent do these symptoms impact your daily living?* This field is required.
Not at all
Mildly
Moderately
Severely
15
TotalBased on answers to questions #3-13
16
What does my score mean?

0-4: indicates minimal symptoms.

5-8: indicates mild symptoms.

9-15: indicates moderate symptoms.

16+: indicates severe symptoms.

What do I do with my score?

Knowing your score empowers you to take an active role in managing your symptoms.

You can use your score to talk with your practitioner about your symptoms and help determine the best support options

You can use the score to monitor changes in your symptoms over time and see how treatments and lifestyle changes affect your symptoms.

Seek support if:

Your score indicates moderate or severe symptoms.

No matter your score, your symptoms impact your ability to perform daily tasks.

Your score indicates minimal or mild symptoms and you would like to know more about how to prepare your body for perimenopause.
17
Which of the following do you currently use to manage your symptoms? (Check all that apply)
Strength training
Cardio-based movement
Stress management techniques
Supplements
Hormone therapy
Complementary therapy (e.g., acupuncture, massage, etc.)
None of the above
All of the above
Other
Other
18
What type of support interests you most? (Check all that apply)
One-on-one coaching
Symptom management strategies
In-person workshops
Lifestyle modifications
Group coaching
On-line resources
Personalized wellness plan
Small group educational sessions
Information about hormone therapy
"Midlife Mindset" support
Other
Should be Empty: