JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Hormone Replacement Therapy Quiz
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name (First, Last)
*
Your answer
Phone Number
*
Your answer
Find out if you might be suffering from a hormonal imbalance. What gender are you?
*
Male
Female
Transgender
How has your energy level been lately?
*
Low
High
Medium
How often do you exercise?
*
Everyday
Every other day
Once a week
Once a month
Never
Do you find it hard to gain or keep muscle mass?
*
Yes
No
Have you found it difficult to lose weight?
*
Yes
No
Are you experiencing hot flashes? *
*
Yes
No
Do you forget why you came into a room or where you put something?
*
yes
No
Are you pleased with your sex drive?
*
yes
No
Do you feel as though you get enough restful sleep at night?
*
yes
no
Are you experiencing night sweats?
*
Yes
No
What age bracket are you in?
*
18-34
35-44
45-54
55-64
65 or above
Do you experience anxiety?
*
Yes
No
How did you hear about us?
*
Your answer
Who can we thank for your referral?
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
