Dr. Jess Hormone Clarity Call Questionnaire

Name* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

Phone Number* This field is required.

Please enter a valid phone number.

How old are you?* This field is required.

Under 35

35-40

41-45

46-50

51-55

56-60

61+

Where are you in your hormone journey?* This field is required.

Still menstruating regularly (predictable cycles)

Cycles becoming irregular/unpredicatable

In perimenopause (diagnosed or suspected)

In menopause (12+ months without a period)

Post-menopause

Not sure - that’s part of why I’m here

What are the TOP 3 symptoms driving you to seek help right now?* This field is required.Check your top 3 but we can note any other symptoms that are present.

Brain fog/difficulty concentrating

Fatigue/low energy

Sleep disruption (trouble falling or staying asleep)

Mood swings/irritability/rage

Anxiety/depression

Weight gain (especially belly area)

Hot flashes/night sweats

Period changes (heavier, lighter, irregular)

Low libido/desire

Joint pain/body aches/muscle weakness/poor recovery

Digestive issues

None of the above

How long have you been dealing with these symptoms?* This field is required.

Less than 6 months

6 months - 1 year

1-3 years

3-5 years

5+ years

Do your symptoms follow any pattern?* This field is required.Select all that apply

They’re worse at certain times of my cycle

They’re worse right before my period

They happen randomly with no pattern

They’ve been constant/ongoing

I’ve never tracked to know if there’s a pattern

I don’t have a cycle anymore

On a scale of 1-10, how much are these symptoms impacting your daily life?* This field is required.1 = minor annoyance, 10 = can barely function

Have you worked with any of the following for your symptoms?* This field is required.Check all that apply

Primary Care Doctor

OB/GYN

Functional Medicine Doctor

Naturopath

Health Coach/Wellness Coach

Nutritionist/Dietitian

Mental Health Provider

No one - I’m handling this on my own

Other

What have you already tried to address these symptoms?* This field is required.Check all that apply

Hormone replacement therapy (HRT/MHT)

Birth control

Antidepressants/anxiety medication

Supplements (specify below)

Diet changes (keto, low-carb, elimination diet, etc.)

Exercise program

Sleep hygiene changes

Stress management/meditation

Nothing yet - I’m just starting to explore

Other

What’s been the most frustrating part of trying to figure this out on your own?* This field is required.2-3 sentences

If we could wave a magic wand and solve ONE thing for you in the next 90 days, what would it be?* This field is required.1-2 sentences

What’s driving you to take action NOW versus 6 months ago?* This field is required.2-3 sentences

Are you currently working with a healthcare provider who manages your hormone-related care?* This field is required.

Yes, and I want to work WITH them using education and support

Yes, but I’m not happy with their approach

No, and I’m looking for guidance on where to start

No, and I prefer to manage this myself with education

Have you ever worked with a Clinical Pharmacist Hormone Educator before?* This field is required.

Yes

I don’t even know what that is

Type option 4

If this is a good fit, are you ready to invest in a program within the next 2-4 weeks?* This field is required.

Yes, I’m ready to get started

Yes, but I need to understand pricing first

Maybe - I want to learn more on the call

Not sure - I’m just exploring options

What’s your biggest hesitation or concern about starting a hormone health program/group?* This field is required.1-2 sentences

Is there anything else you want me to know before our call?

Dr. Jess Hormone Clarity Call Questionnaire