Are you experiencing any
of these symptoms?
Choose up to 5 options
Choose up to 5 options
1
Stubborn belly weight
2
Low energy
3
Sugar cravings
4
Bloating
5
Poor sleep
6
Hot flashes
7
Mood swings
8
No, not me.
Are you going
through any of these?
Please choose an option
Please choose an option
1
Perimenopause
2
Menopause
3
Post Menopause
4
Hormonal changes
5
I’m not sure yet
What best describes your
current energy level?
Choose one
Choose one
1
I feel tired most of the time
2
I feel tired about half of the week
3
I feel tired, but only 1–2 days a week
4
I feel energized all week long
How would you describe
your quality of sleep?
Choose one
Choose one
1
Terrible
2
Light / Interrupted
3
Could Be Better
4
Deep
Do you notice digestive
discomfort?
Choose as many as apply
Choose as many as apply
1
Bloating, Gas or Stomach Cramps
2
Food Sensitivities or Intolerances
3
Diarrhea or Constipation
4
No, I don't have any of these digestive issues
How would you describe
your emotional state
lately?
Choose one
Choose one
1
Emotional ups & downs
2
I feel stressed or overwhelmed
3
I feel low, anxious or not like myself
4
I feel calm, positive and emotionally balanced
How does your weight
show up for you?
Choose as many as apply
Choose as many as apply
1
I eat and move the same, but my weight keeps increasing
2
My clothes suddenly don’t fit anymore
3
All my weight goes straight to my belly
4
I don’t have weight issues
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