24GXCFG01-Graminex Menopause

Do we have your consent to ask you some questions related to your lifestyle and medical history and to contact you regarding this study? (If you answer No, this survey will end). If you answer NO, this survey will end.

YESNO

Your Privacy Is Important to Us

We want to ensure the data we collect can be verified by researchers and send updates on the study should you qualify to participate. All information recorded will be maintained with the strictest confidentiality except as required by law. For more information, please review our Privacy Policy

Name

First Name

Last Name

example@example.com

Phone Number

Please enter a valid phone number.

Please Enter Your Date of Birth

Date

What is your current height?

Height Number

Height Metric

What is your current weight?

Weight Number

Weight Metric

What was your assigned sex at birth?

Male

Female

Are you presently pregnant, planning to become pregnant or presently breastfeeding?

Yes

I can no longer get pregnant.

Being as you are female; it is important that during this study you do not become pregnant. What method of birth control are you currently using and will continue to use during the duration of the study.

Hormonal contraceptives (Oral, birth control patches, Vaginal Contraceptives (NuvaRing), Injectable contraceptives (Depo-Provera, Lunelle) or hormone Implants (Norplant System))

Double-Barrier method

Intrauterine Device

Non-heterosexual lifestyle or you agree to use contraception if planning on changing to heterosexual lifestyle

Vasectomy of partner (must have occurred at least 6 months ago)

Abstinence

Currently not using any form of birth control

I can no longer become pregnant because of:

Hysterectomy

Unilateral Oophorectomy

Uterine Ablation

Menopause

Currently not using any form of birth control

When was your period (menses)?

Last Month

> 6 months ago

6-12 months ago

> 12 months ago

12-24 Months Ago

> 2 years ago

Have you been experiencing regular hot flashes and/or night sweats?

YESNO

Over the last 6 months have you been experiencing any of the following?

Sleep Disturbances

Joint Pain

Mood Changes

Fatigue or Lack of Energy

Vaginal Dryness

Urinary Changes

Changes in Sexual Function

We will now ask you a series of questions (11) in regard to your menopause symptoms please answer to the best of you ability.

Following the scale below how would you rate your hot flashes, sweating (episodes of sweating)?

None

Mild

Moderate

Severe

Extremely Severe

Following the scale below how would you rate your heart discomfort (unusual awareness of heart beating, heart skipping, heart racing, tightness)

None

Mild

Moderate

Severe

Extremely Severe

Following the scale below how would you rate your Sleep Problems (difficulty in falling asleep, difficult sleeping through the night, waking up early)

None

Mild

Moderate

Severe

Extremely Severe

Following the scale below how would you rate your Depressive Mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)

None

Mild

Moderate

Severe

Extremely Severe

Following the scale below, how would your rate your Anxiety (inner restlessness, feeling panicky)

None

Mild

Moderate

Severe

Extremely Severe

Following the scale below, how would you rate your Physical and Mental Exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)

None

Mild

Moderate

Severe

Extremely Severe

Following the scale below, how would rate your Sexual Problem (changes in sexual desire, in sexual activity and satification)

None

Mild

Moderate

Severe

Extremely Severe

Following the scale below, how would you rate your Bladder Problems (difficulty urinating, increase need to urinate, bladder incontienence)

None

Mild

Moderate

Severe

Extremely Severe

Following the scale below, how would you rate your Dryness of Vagina (sensation of dryness or burning of vagina, difficult with sexual intercourse)

None

Mild

Moderate

Severe

Extremely Severe

Following the scale below, how would you rate your Joint and Muscular Discomfort (pain in the joints, rheumatoid complaints)

None

Mild

Moderate

Severe

Extremely Severe

Do you have an allergy or sensitivity/intolerance to bees, bee products or pollen?

YESNO

Have you been diagnosed with asthma?

YESNO

Do you use medications regularly to control it?

YESNO

What kind of medications?

Have you been diagnosed with any of the following?

Anxiety Disorder

Sleep Disorder (e.g. Sleep Apnea)

Major Depression

Have you had a history of alcohol or illicit drug abuse, known drug dependence, or are seeking or have sought treatment for alcohol or substance abuse related disorders within the past 12 months?

YESNO

Do you regularly drink alcohol?

YESNO

On average, how many standard alcoholic drinks do you consume per week?

None

Two or Less

3 to 5

6 to 9

10 to 14

15 or More

Do you use tobacco or nicotine products (e.g., cigarettes, vapes, e-cigarettes)?

I currently smoke.

No, I no longer smoke.

I have never smoked.

Do you use cannabis products?

YESNO

Reason for Using Cannabis

Prescribed by Health Care Provider

Recreational Use

How often do you use recreational cannabis?

Daily or 5-7+ times per week

Regularly or 3-4 times per week

Weekly or 1-2 times per week

Monthly or 1-3 times per month

Occasionally / less than once per month

How do you consume cannabis?

Drops

Edibles

Smoking/Vaping

Cream

Other

Have you had a major surgery in the past 3 months or plan to have surgery in the next 3 months?(including gastric bypass or other weight loss surgeries)

YESNO

Have you been diagnosed with any of the following medical conditions?

Type 1 or Type 2 Diabetes

Thyroid-Related Disorder

Chronic Kidney or Liver Disease

Hypertension (High Blood Pressure)

History of Cardiovascular Disease or Cardiac Event

Current or History of Gastrointestinal Issues

Gastrointestinal Disease that result in malabsorption ( e.g., IBS, Crohn's, Ulcerative Colitis, IBD)

Metabolic Disease (PCOS, Metabolic Syndrome e.g.)

Autoimimmune Disease or Immune Compromised

HIV, HepB or Hep C Positive

Blood/Bleeding Disorders

Muskoskeletal Disorders

Neurological or Psychological Conditions (ex. Depression, Anxiety, Epilepsy)

Urogenital Disease/Disorders (STDs, UTIs, CIN)

Other

If other, please indicate you condition.

Did you select kidney issues because you have/had kidney stones?

YESNO

Have you been symptoms free for the past 6 months?

YESNO

Have you had a significant cardiovascular events in the past 6 months?

YESNO

Is your medical condition currently in stable condition (have been treated for at least 3 months with no changes in medications), that is, you are being followed by a physician and taking prescribed medication to control their condition?

YESNO

Are you taking medications to control your condition?

YESNO

How long have you been taking your medications

1-2 months

3-5 months

Over 6 months

Over 1 year

Have you had/been diagnosed with cancer in the past 5 years or are you currently receiving chemotherapy or radiation?This does not include skin cancer (basal cell carcinoma) that has been fully excised without chemotherapy or radiation.

YESNO

Please indicate which, if any, of the following prescription medications you take:

Selective estrogen-receptor modulators (raloxifene, tamoxifen)

Hormone replacement therapy

Hormonal contraceptives

Antidepressants, unless on a stable dose for at least three months

Fezolinetant (neurokinin-3 antagonist) to treat hot flashes

Sleep medications (e.g., benzodiazepines, zopiclone, suvorexant)

None of the above

Do you use any other prescription medication daily?

YESNO

Please list your medications.

Do you use any of the following over-the-counter medications or supplements?

Black Cohosh

Phytoestrogen supplements

St. John’s Wort

Dong Quai

Soy-germ extract

Flower pollen extract

Bee pollen

Melatonin or other supplements for improving sleep

Other OTC supplements marketed for menopause symptom relief

None of the above

Have you been taking these over-the-counter medications/supplements for at least 3 months?

YESNO

Are you currently taking other supplements?

YESNO

Please list below:

Have you donated blood in the last 30 days or plan to in the next 30 days post?

YESNO

Will you be willing to maintain your current lifestyle habits throughout the study, including diet, medications, supplements, sleep, exercise and avoid taking any new supplements?

YESNO

Have you participated in a clinical trial within the last 30 days?

YESNO

How did you hear about this study?Please tick all that apply

Facebook

Instagram

Website

Radio

Google

Flyers

YouTube

TikTok

Someone Referred Me

Other

Please describe where you heard about that study.

Please provide contact information for the person who referred you so we can thank them. Name & Email

Why did you decide to apply for participation in this study?

Interest in the topic being studied

Compensation being offered for participation

Have participated in clinical trial before.

Other

What was the other reason you decided to apply?

I consent to receiving communications from KGK Science Inc. and their third-party service providers (via electronic mail, electronic message, telecommunication, and automatic dialing-announcing device including the use of pre-recorded or synthesized voice messages). Your information will not be shared with and/or sold to external companies and is only used for communications with KGK Science.

YESNO