1

First — are you male or female?

Male

Female

2

What is your date of birth?* This field is required.

Date

3

hidden_current_date

Date

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.

First Name

Last Name

Please enter your email

Please enter your mobile phone number

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