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The Femality Assessment1
1
Welcome to our Femality assessment! This will only take a few minutes. Please answer as honestly as possible. The answers will give us valuable information that will be forwarded to our physicians and initiate your personalized treatment plan!
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What's your email?
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example@example.com
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What's your age?
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Where in your menopause journey are you?
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Pre-menopause
Peri-menopause
Menopause
I'm not sure
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5
What was the date of your last period?
*
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-
Date
Month
Day
Year
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6
Do you or anyone in your family have a history of ovarian cancer?
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Yes
No
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Do you or anyone in your family have a history of breast cancer?
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Yes
No
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8
Are you currently taking any medications? If yes, please list them below:
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9
Did you undergo any surgery in the past? If so, please list them.
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10
Are you currently experiencing physical, mental or sex-related symptoms?
Yes
No
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11
What symptoms are you currently experiencing
Hot Flashes/Night Sweats
Depression
Vaginal Dryness/Atrophy
Insomnia
Brain Fog/Lack of Focus
Mood Swings
Low Libido
Anxiety
Weight Gain
Osteoporosis
Frequent UTIs
Hair Loss
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12
On a scale of 1-5, please specify the severity of each symptom.
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13
Hot Flashes/Night Sweats
Hot flashes are the sudden feeling of warmth in the upper body, which is usually most intense over the face, neck and chest.
1
2
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5
Not a Problem
Unbearable
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Fatigue
Fatigue
is a lingering tiredness that is constant and limiting. With
fatigue
, you have unexplained, persistent, and relapsing exhaustion
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2
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4
5
Not a Problem
Unbearable
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Depression
Depression
is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning.
1
2
3
4
5
Not a Problem
Unbearable
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Anxiety
Anxiety
is your body's natural response to stress. It's a feeling of fear or apprehension about what's to come.
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2
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4
5
Not a Problem
Unbearable
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Mood Swings
Mood swings
can be normal, and are only an indicator of underlying disease when feelings become excessive, all-consuming, and interfere with daily living.
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5
Not a Problem
Unbearable
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Insomnia
Insomnia
is a sleep disorder in which you have trouble falling and/or staying asleep. The condition can be short-term (acute) or can last a long time (chronic). It may also come and go.
1
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5
Not a Problem
Unbearable
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Brain Fog
Brain fog
is a symptom of another medical condition. It's involves memory problems, a lack of mental clarity, and an inability to focus.
1
2
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5
Not a Problem
Unbearable
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Low Libido
Low libido
describes a decreased interest in sexual activity.
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4
5
Not a Problem
Unbearable
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21
Weight Gain
Weight gain
can have causes that aren't due to underlying disease. Examples include overeating, physical inactivity, age, or medication side effects.
1
2
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5
Not a Problem
Unbearable
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22
UTIs
A urinary tract infection (
UTI
) is an infection in any part of your urinary system.
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4
5
Not a Problem
Unbearable
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23
Hair Loss
Hair loss
(alopecia) can affect just your scalp or your entire body, and it can be temporary or permanent.
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2
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5
Not a Problem
Unbearable
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Stomach Pains
Abdominal pain can have causes that aren't due to underlying disease. Examples include constipation, gas, overeating, stress, or muscle strain.
1
2
3
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5
Not a Problem
Unbearable
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25
Vaginal Atrophy/Dryness
Vaginal atrophy (atrophic vaginitis) is thinning, drying and inflammation of the vaginal walls that may occur when your body has less estrogen.
1
2
3
4
5
Not a Problem
Unbearable
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26
How would you rate your level of daily stress?
1
2
3
4
5
Not a Problem
Unbearable
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27
Do you have any relationship concerns/stresses?
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Yes
No
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28
Do you use electronic devices or watch TV before bed?
*
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Yes
No
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29
Do you tend to nap during the day?
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Yes
No
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30
Do you have difficulty sleeping/staying asleep?
*
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Yes
No
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31
How many hours of sleep do you get a night (on average) ?
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Number Only
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32
How often do you exercise?
*
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Never
Rarely (monthly)
Sometimes (weekly)
Often (multiple times a week)
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33
How do you exercise?
Running
Walking
Cycling
Weight Lifting
Yoga
Dance Class
Sports
Other
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34
Are you smoking? If yes, how many packs a day?
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35
Do you drink caffeine in the afternoons?
*
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Number Only
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36
Describe your diet on a normal day? Breakfast, Lunch and Dinner.
*
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Discuss legume, bean and veggie intake.
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37
Do you have any food allergies. Please list them below.
*
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Discuss legume, bean and veggie intake.
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38
Are you using alcohol > 2x a month?
*
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Yes
No
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39
How often do you eat preservatives/processed/packaged foods?
*
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Very Often
Sometimes
Rarely
Never
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40
How often do you eat meat?
*
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Very Often (Almost Everyday)
Sometimes (Once a week or less)
Rarely
Never
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41
How much does menopause affect the quality of your life?
*
This field is required.
1
2
3
4
5
Not at all
Chronically
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42
How much do you know about the menopause transition from peri-menopause to post-menopause?
*
This field is required.
1
2
3
4
5
No Knowledge
I'm an expert!
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43
What are you most willing to do, in order to improve your health outcomes?
*
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Exercise More
Eat Better
Reduce Stress
Manage Depression
Sleep Better
Reduce my Exposure to Environmental Toxins
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44
What have you tried to relieve your symptoms until now?
*
This field is required.
Lifestyle Changes
Nutritional Changes
Supplements
Medications/Hormonal Replacement Therapy (HRT)
Coaching/Therapy
Other
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45
Please elaborate on what treatment options have worked for you?
*
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Dosages, Names of Supplements, Lifestyle Changes etc.
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46
What treatment avenues are you interested in exploring?
*
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Lifestyle Changes
Nutritional Changes
Supplements
Hormonal Replacement Therapy (HRT)
Coaching/Therapy
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47
Occupation
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48
Name
*
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First and Last Name
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49
Address
*
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In what state, do you reside?
Street Address
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
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Algeria
American Samoa
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Angola
Anguilla
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Aruba
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Azerbaijan
The Bahamas
Bahrain
Bangladesh
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Belgium
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Bermuda
Bhutan
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Botswana
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Burkina Faso
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Canada
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Chile
China
Christmas Island
Cocos (Keeling) Islands
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Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
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Democratic Republic of the Congo
Denmark
Djibouti
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Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
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Guinea
Guinea-Bissau
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Iraq
Ireland
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Kiribati
North Korea
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Kosovo
Kuwait
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Laos
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Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
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Mayotte
Mexico
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Nagorno-Karabakh
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Nauru
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Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
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Tuvalu
Uganda
Ukraine
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United Kingdom
Uruguay
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Vanuatu
Vatican City
Venezuela
Vietnam
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Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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