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Your Name
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First Name
Last Name
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Your Birthday
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Date
Month
Day
Year
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Your Email Address
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example@example.com
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Do you get your period?
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Yes, regularly
Yes but irregularly
Not anymore
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5
Do you currently use birth control or hrt?
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YES
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6
What type(s) of hormones do you currently use?
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Oral pill
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Topical Cream or Gel
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7
Let's Talk Symptoms
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Tell us what's going so we can identify your best options. And don't hold back!, The more we know the better! How often do you experience any of the following.....
None
Sometimes
Often
OMG - Awful
Fatigue or Energy Loss
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Dizziness or Headaches
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Row 1, Column 2
Row 1, Column 3
Body Aches, Joint Pain or Frozen Shoulder
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Mood, Anxiety, Rage, Depression
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Racing Heart or Heart Palpitations
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Low Libido
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Urinary Incontinence
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Increased Response to Allergies
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Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Increased GI Problems
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Brain Fog or Memory Loss
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Weight Gain or Metabolism Changes
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Burning Tongue, Dry Mouth/Thirst
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Tingling or Shock Sensations
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Skin, Hair, or Nail Changes
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Vaginal Dryness, Itchiness or Painful Sex
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Irregular Bleeding
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Row 15, Column 3
Insomnia or Sleep Disruption
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Hot Flashes and/or Night Sweats
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Row 17, Column 3
Fatigue or Energy Loss
Dizziness or Headaches
Body Aches, Joint Pain or Frozen Shoulder
Mood, Anxiety, Rage, Depression
Racing Heart or Heart Palpitations
Low Libido
Urinary Incontinence
Increased Response to Allergies
Increased GI Problems
Brain Fog or Memory Loss
Weight Gain or Metabolism Changes
Burning Tongue, Dry Mouth/Thirst
Tingling or Shock Sensations
Skin, Hair, or Nail Changes
Vaginal Dryness, Itchiness or Painful Sex
Irregular Bleeding
Insomnia or Sleep Disruption
Hot Flashes and/or Night Sweats
None
Row 0, Column 0
Sometimes
Row 0, Column 1
Often
Row 0, Column 2
OMG - Awful
Row 0, Column 3
None
Row 1, Column 0
Sometimes
Row 1, Column 1
Often
Row 1, Column 2
OMG - Awful
Row 1, Column 3
None
Row 2, Column 0
Sometimes
Row 2, Column 1
Often
Row 2, Column 2
OMG - Awful
Row 2, Column 3
None
Row 3, Column 0
Sometimes
Row 3, Column 1
Often
Row 3, Column 2
OMG - Awful
Row 3, Column 3
None
Row 4, Column 0
Sometimes
Row 4, Column 1
Often
Row 4, Column 2
OMG - Awful
Row 4, Column 3
None
Row 5, Column 0
Sometimes
Row 5, Column 1
Often
Row 5, Column 2
OMG - Awful
Row 5, Column 3
None
Row 6, Column 0
Sometimes
Row 6, Column 1
Often
Row 6, Column 2
OMG - Awful
Row 6, Column 3
None
Row 7, Column 0
Sometimes
Row 7, Column 1
Often
Row 7, Column 2
OMG - Awful
Row 7, Column 3
None
Row 8, Column 0
Sometimes
Row 8, Column 1
Often
Row 8, Column 2
OMG - Awful
Row 8, Column 3
None
Row 9, Column 0
Sometimes
Row 9, Column 1
Often
Row 9, Column 2
OMG - Awful
Row 9, Column 3
None
Row 10, Column 0
Sometimes
Row 10, Column 1
Often
Row 10, Column 2
OMG - Awful
Row 10, Column 3
None
Row 11, Column 0
Sometimes
Row 11, Column 1
Often
Row 11, Column 2
OMG - Awful
Row 11, Column 3
None
Row 12, Column 0
Sometimes
Row 12, Column 1
Often
Row 12, Column 2
OMG - Awful
Row 12, Column 3
None
Row 13, Column 0
Sometimes
Row 13, Column 1
Often
Row 13, Column 2
OMG - Awful
Row 13, Column 3
None
Row 14, Column 0
Sometimes
Row 14, Column 1
Often
Row 14, Column 2
OMG - Awful
Row 14, Column 3
None
Row 15, Column 0
Sometimes
Row 15, Column 1
Often
Row 15, Column 2
OMG - Awful
Row 15, Column 3
None
Row 16, Column 0
Sometimes
Row 16, Column 1
Often
Row 16, Column 2
OMG - Awful
Row 16, Column 3
None
Row 17, Column 0
Sometimes
Row 17, Column 1
Often
Row 17, Column 2
OMG - Awful
Row 17, Column 3
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