Menopause Assessment

What is your date of birth?

Month:

Day:

Year:

What is your gender?

FEMALE

MALE

What is your height and weight?

Height (ft):

Height (in):

Weight (lbs):

Which of the following menopausal symptoms are you experiencing?

Hot flashes

Night sweats

Mood swings or irritability

Sleep disturbances

Vaginal dryness

Low libido

Fatigue and low energy

Brain fog or memory issues

Weight gain, especially around midsection

Hair loss or thinning

Skin changes (dryness, aging)

None of the above

Which stage of menopause do you believe you are in?

Premenopause - Regular periods

Perimenopause - Irregular periods

Menopause - No periods for 12+ months

Postmenopause - 5+ years since last period

Unsure

How would you rate the severity of your menopausal symptoms?

None - No symptoms

Mild - Noticeable but manageable

Moderate - Some interference with daily life

Severe - Significant impact on daily life

Very Severe - Major impact on quality of life

How would you describe your current stress levels?

Very Low - I rarely feel stressed

Low - I experience minimal stress

Moderate - I experience some stress but manage it well

High - I frequently feel stressed and overwhelmed

Very High - I feel constantly stressed and struggle to cope

How would you describe your sleep quality?

Excellent - Deep, restorative sleep every night

Good - Generally restful sleep most nights

Moderate - Some sleep issues but mostly restful

Poor - Frequent sleep problems affecting daily life

Very Poor - Severe sleep issues

Do you have a family history of hormonal disorders?

None known

Early menopause

Diabetes (Type 1 or Type 2)

Thyroid disorders

Polycystic Ovary Syndrome (PCOS)

Infertility issues

Other hormonal disorders

Have you had any recent blood tests for hormone levels?

No recent tests

Basic hormone panel

Comprehensive hormone panel

Regular monitoring

How would you rate your overall hormonal health during menopause?

Excellent - Managing symptoms well

Good - Some symptoms but manageable

Moderate - Significant symptoms but coping

Poor - Difficult symptoms affecting quality of life

Very Poor - Severe symptoms significantly impacting life

Contact Information

Your information is secure and will be used to create your personalized health assessment.

First Name

Last Name

Email Address

Phone Number

We respect your privacy and will never share your information with third parties.

Low T. High Impact.

What is your date of birth?

What is your gender?

What is your height and weight?

Which of the following menopausal symptoms are you experiencing?

Which stage of menopause do you believe you are in?

How would you rate the severity of your menopausal symptoms?

How would you describe your current stress levels?

How would you describe your sleep quality?

Do you have a family history of hormonal disorders?

Have you had any recent blood tests for hormone levels?

How would you rate your overall hormonal health during menopause?

Contact Information

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