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Women's Hormone Self Assessment
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Please rate to what degree do you experience the following:
Difficulty Concentrating
*
None
1
2
3
4
Severe
Can’t Sleep (Insomnia)
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None
1
2
3
4
Severe
Anxious
*
None
1
2
3
4
Severe
Moodiness/Emotional Swings
*
None
1
2
3
4
Severe
Depressed or Unhappy
*
None
1
2
3
4
Severe
Difficulty Remembering Things
*
None
1
2
3
4
Severe
Brain Fog
*
None
1
2
3
4
Severe
Headaches
*
None
1
2
3
4
Severe
Painful or Swollen Breasts
*
None
1
2
3
4
Severe
Weight gain/Bloating
*
None
1
2
3
4
Severe
PMS
*
None
1
2
3
4
Severe
Night Sweats
*
None
1
2
3
4
Severe
Hot Flashes
*
None
1
2
3
4
Severe
Vaginal Dryness
*
None
1
2
3
4
Severe
Dry Hair/Skin
*
None
1
2
3
4
Severe
Painful Intercourse
*
None
1
2
3
4
Severe
Lack of Sexual Desire
*
None
1
2
3
4
Severe
Inability to Reach Orgasm
*
None
1
2
3
4
Severe
Fatigue/Loss of Energy
*
None
1
2
3
4
Severe
Incontinence
*
None
1
2
3
4
Severe
Frequent Urinary Tract Infections
*
None
1
2
3
4
Severe
Thank you!
*
MM
/
DD
/
YYYY
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