Questionnaire 1. Check The Symptoms You Experience (Select All That Apply): a. Suffering From Constant Fatigue b. Feeling Down, Depression, Or Moody c. Having Trouble Sleeping d. Trouble Concentrating e. Sexual Dysfunction f. Experiencing Night Sweats Or Heat Flashes g. Pain In Your Joints h. Weight Gain Or Bloating i. A Decrease In Your Sex Drive j. Bladder Leakage k. Heavy Menstrual Bleeding l. Having A Hard time getting up in the morning m. Vaginal Dryness or Erectile Dysfunction2. Which Of The Following Are You Wanting To Help Increase In Your Life? (Select All That Apply): a. Improved Sense Of Well-being b. Vaginal Lubrication c. Increase In Mental & Physical Energy d. Sex Drive & Sexual Performance e. Muscle Tone f. Quality Of Sleep g. Levels Of Concentration3. Which Of The Following Are You Wanting To Help Decrease In Your Life? (Select All That Apply): a. Bladder Leakage b. Levels Of Depression Or Anxiety c. Night Sweats Or Heat Flashes d. Pain In Your Joints e. Menstrual Flow f. Vaginal Dryness Or Painful Sex g. Weight Gain Or Bloating h. Constant Fatigue4. Over The Last Year, What Have You Done To Maintain A Healthy And Fit Lifestyle? (Select All That Apply): a. Started A Healthy Eating Lifestyle b. Joined A Fitness Program (Gym, Training, Etc.) c. Kept A Consistent Active Lifestyle (Walking, Playing Sports, Jogging, Etc.) d. Continued A Moderate Active Lifestyle (Walking, Playing Sports, Jogging, Etc.) e. Tried To Reduce Levels Of Stress (Meditation, Yoga, Etc.) f. Reduced Or Eliminated Smoking Habits Or Drinking Alcohol g. Tried To Stay On A Consistent Sleep ScheduleName First Last PhoneEmail
