Hormone Age Questionnaire

1
First — are you male or female?
Male
Female
2
What is your date of birth?* This field is required.
Date
Month
Day
Year
3
hidden_current_date
Date
Month
Day
Year
4
hidden_biological_age
5
I feel tired or fatigued even after a full night of sleep.* This field is required.Your answer should reflect the past 30 days.
Never
Sometimes
Often
Always
6
I feel low energy or sluggish, even when I've had enough rest.* This field is required.Your answer should reflect the past 30 days.
Never
Sometimes
Often
Always
7
I have trouble falling asleep, staying asleep, or I wake up unrefreshed.* This field is required.Your answer should reflect the past 30 days.
Never
Sometimes
Often
Always
8
My sleep quality has declined — I wake up feeling unrested or have trouble staying asleep.* This field is required.Your answer should reflect the past 30 days.
Never
Sometimes
Often
Always
9
I experience brain fog, forgetfulness, or difficulty concentrating.* This field is required.Your answer should reflect the past 30 days.
Never
Sometimes
Often
Always
10
I have difficulty focusing, experience brain fog, or my mental sharpness has declined.* This field is required.Your answer should reflect the past 30 days.
Never
Sometimes
Often
Always
11
I feel more anxious, irritable, or emotionally sensitive than I used to.* This field is required.Your answer should reflect the past 30 days.
Never
Sometimes
Often
Always
12
I feel more irritable, short-tempered, or less emotionally resilient than before.* This field is required.Your answer should reflect the past 30 days.
Never
Sometimes
Often
Always
13
I'm gaining weight — especially around my belly — even though my diet hasn't changed.* This field is required.Your answer should reflect the past 30 days.
Never
Sometimes
Often
Always
14
I'm gaining body fat (especially around the midsection) and losing muscle, despite exercising.* This field is required.Your answer should reflect the past 30 days.
Never
Sometimes
Often
Always
15
My sex drive or interest in intimacy has noticeably decreased.* This field is required.Your answer should reflect the past 30 days.
Never
Sometimes
Often
Always
16
My sex drive or libido has decreased significantly from what it used to be.* This field is required.Your answer should reflect the past 30 days.
Never
Sometimes
Often
Always
17
Which of the following best describes your current situation?* This field is required.Your answer should reflect the past 30 days.
My periods are regular and I have no menopausal symptoms
My periods are becoming irregular or I have occasional hot flashes
I'm experiencing perimenopause symptoms (hot flashes, night sweats, mood shifts)
I am in or past menopause
18
How has your physical strength and stamina changed in the last 1-2 years?* This field is required.Your answer should reflect the past 30 days.
No change - still feel strong and capable
Slight decline - takes more effort to maintain
Noticeable decline - workouts feel harder, recovery takes longer
Significant decline - I've largely stopped exercising because it doesn't seem to work
19
I feel less motivated, enthusiastic, or driven about life, work, or hobbies than I used to.* This field is required.Your answer should reflect the past 30 days.
Never
Sometimes
Often
Always
20
My drive, ambition, or competitive edge has decreased significantly.* This field is required.Your answer should reflect the past 30 days.
Never
Sometimes
Often
Always
21
hidden_symptom_score
22
hidden_age_modifier
23
hidden_hormone_age
24
hidden_score_tier
25
You're almost there.

Based on your answers, we're calculating your personal Hormone Age right now.

Where should we send your free Synergy Hormone IQ Report? You'll see your results on the very next screen.
26
Where should we send your report?* This field is required.If your results indicate you may benefit from hormone optimization, what would you most likely do next?
First Name
Last Name
Please enter your email
Please enter your mobile phone number
Please Select
Please Select
I'd like to schedule a consultation as soon as possible.
I'd like someone to contact me to answer my questions first.
I'd like to review my results before deciding.
I'm not looking for treatment at this time.
If your results indicate you may benefit from hormone optimization, what would you most likely do next?
27
I understand that this assessment and any resulting score, report, or insights are for general educational purposes only. This is not a medical evaluation, does not establish a doctor-patient relationship, and has no correlation with any clinically validated diagnostic tool. Any hormone optimization treatment requires a full evaluation by a licensed medical provider, and individual results cannot be guaranteed.* This field is required.
I agree
28
By submitting this form, I consent to receive my Hormone IQ results, personalized report, and related follow-up communications from Synergy Wellness Center by both email and SMS text message. Message and data rates may apply. I may opt out at any time by replying STOP to any text message or clicking unsubscribe in any email.* This field is required.
I agree
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