Verdant Body Online Program and Community Application

1
Which statement best describes your current status?* This field is required.
Actively trying to conceive
Preparing for a baby in the future
Regulating my cycle is more of a concern, not really thinking about fertility
I want to optimize my health. Have some cycle concerns along with some other chronic complex health issues
Other
2
What is your age?* This field is required.
18-21
22-29
30-40
40+
3
Have you been diagnosed with any of the following conditions?* This field is required.
Endometriosis
Polycystic Ovary Syndrome (PCOS/PMOS)
Fibroids
Chronic Pelvic Pain
PMDD
Adenomyosis
Dysmenorrhea
Amenorrhea
No. I have no formal diagnosis.
Other
4
Please select all statements that are true for you:* This field is required.
Irregular cycles (never know when period is coming)
Heavy bleeding at start of period (wear multiple layers of protection)
Period pain that prevents you from daily activities
Unsure if ovulating
Large clots in menstrual blood
Spotting outside of your period
Cycles longer than 30 days (from first day of bleeding to next first day of bleeding)
Bleed for 2 or less days each period
Cycles are shorter than 26 days (from first day of bleeding to next first day of bleeding)
I have not had a period for over 6 months
None of the above apply to me
Other
5
Which of these other symptoms do you regularly experience?* This field is required.
PMS/PMDD
Anxiety/Depression
Fatigue/Exhaustion
Systemic Inflammation/Immune system dysreguation
Migraines/Headaches
High Cholesterol
Elevated Blood sugar
NAFLD
Digestive issues (IBS/IBD, chronic constipation, bloating, etc)
None of the above
Other
6
What are the top 3 complaints you would like to see resolved?* This field is required.
7
What question would you most like answered about your menstrual cycle or other related health issue?* This field is required.
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8
Do you have other chronic health issues not listed above?* This field is required.
9
What therapies have you tried previously? Roughly how much do you think you have spent trying to treat these issues?* This field is required.Practitioners, programs, courses, retreats, supplements, medications, products, etc.
10
What were your successes with previous therapies?* This field is required.Progress made? Practices or supplements you still use?
11
What were your failures with previous therapies?* This field is required.Too expensive? Too hard? Not enough support? Poor communication with practitioner?
12
What are some of your biggest hurdles stopping you from having an optimal cycle at this moment? How much time, energy, effort are you able to devote to this issue?* This field is required.
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13
Full Name* This field is required.
First Name
Last Name
14
Email Address* This field is required.
example@example.com
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