Please check "YES" for all current symptoms or those present within the last 6 months that occur on a REGULAR basis. Regular meaning greater than 3x/wk OR regular enough to be significantly impacting the quality of your life on a daily or weekly basis

Select "NO" for any that do not apply

Emotionally Fragile *

Yes

Difficulty with memory *

Yes

Periods are less than 3 days *

Yes

Struggle with depression or anxiety *

Yes

Hot flashes or night sweats *

Yes

Recurrent Bladder Infections *

Yes

Urinary Leakage *

Yes

Difficulty Sleeping/Waking throughout the night *

Yes

Breasts have gotten smaller / beginning to droop *

Yes

Achy Joints *

Yes

Sun damaged skin is more noticeable *

Yes

I am noticing more fine lines and wrinkles *

Yes

Dry thinning hair *

Yes

Vaginal Dryness or Pain with intercourse *

Yes

No Interest in sex *

Yes

Bloating or puffiness *

Yes

Irritable / mood swings *

Yes

Heavy, painful periods *

Yes

Gaining weight (esp. around hips, butt, and thighs) *

Yes

Difficulty losing weight *

Yes

Sometimes crying over nothing *

Yes

Gallbladder problems *

Yes

I've been told by doctors I have fibroids *

Yes

Migraines or other headaches *

Yes

I have brain fog or feel like my memory isn't quite what it used to be *

Yes

I'm losing hair (scalp, body, outer third of eyebrows) *

Yes

My hair is dry and tangles easily *

Yes

Chronic constipation (often need to use a stimulant or caffeine to have a bowel movement) *

Yes

Always cold and/or have cold hands and feet *

Yes

Periods are sporadic or occur more than 35 days apart *

Yes

I have joint or muscle pain *

Yes

Difficulty getting pregnant (after trying for 6 months) *

Yes

1st Trimester miscarriage *

Yes

Low mood or struggle with depression *

Yes

Struggle to feel rested after 8-9+ hours of sleep *

Yes

Difficult to break a sweat *

Yes

recurrent headaches *

Yes

High cholesterol *

Yes

Hoarseness in your voice most days *

Yes

Chronic fatigue / lethargy *

Yes

Brittle nails *

Yes

Unexplained weight gain *

Yes

Enlarged tongue *

Yes

Frequent nervousness / anxiety *

Yes

Prone to panic attacks *

Yes

Difficulty falling asleep / insomnia *

Yes

Irritability *

Yes

Excess sweating / always hot *

Yes

Heart palpitations / increased heart rate *

Yes

Excessive hunger *

Yes

Unintentional weight loss *

Yes

Tired in morning even after full night's sleep *

Yes

Dependent on caffeine *

Yes

Want to take naps most days *

Yes

Afternoon energy crash *

Yes

Crave salty or sweet food *

Yes

Dizzy when standing up too fast *

Yes

Feeling at the mercy of my stress *

Yes

Difficulty falling / staying asleep *

Yes

Muscles feel weaker *

Yes

Get sick often and/or have a difficult time getting over infections *

Yes

Low blood sugar issues (fasted glucose <70mg/dl) *

Yes

My life is crazy stressful *

Yes

Constantly overwhelmed by stress *

Yes

Extra weight around midsection *

Yes

Difficulty falling asleep or staying asleep *

Yes

My body is tired at night but my mind is going a mile a minute *

Yes

I get a 2nd wind at night that keeps me from falling asleep *

Yes

Waking up between 2-4am and struggling to fall back asleep *

Yes

Easily distracted, especially when under stress *

Yes

I get angry quickly or just feel on edge *

Yes

High blood pressure or a fast heart rate *

Yes

Elevated blood sugar / diabetes *

Yes

I get shaky if I don't eat often *

Yes

Prone to injury / difficulty healing *

Yes

"Wired and tired" *

Yes

Low libido or diminished sex drive *

Yes

No motivation *

Yes

Struggle with depression, having mood swings, or cry easily *

Yes

Tired or fatigued throughout the day *

Yes

Diagnosed with chronic fatigue syndrome

Yes

Unable to gain muscle or losing muscle mass *

Yes

Decrease in bone density / prone to fractures / diagnosed osteoporosis *

Yes

Urinary incontinence (Leakage/lack of control) *

Yes

Difficulty or unable to orgasm *

Yes

Cardiovascular symptoms or heart disease *

Yes

I struggle with weight gain despite attempting to eat health and exercise *

Yes

Anxiety or panic attacks *

Yes

Abnormal hair growth on face, chest, or stomach *

Yes

Acne that does not respond to topical treatments *

Yes

Oily skin / hair *

Yes

Areas of darker skin (I.e. neck or armpits) *

Yes

Thinning hair / hair loss on head *

Yes

I struggle with depression and/or anxiety *

Yes

I have been medically diagnosed by my PCP or OB/GYN with PCOS *

Yes

I have had a difficulty getting pregnant (after trying for 6 or more months *

Yes

Experience PMS symptoms 7-10 days before period *

Yes

Headaches or migraines around period *

Yes

Feel anxious often *

Yes

Painful, heavy, difficult periods *

Yes

Agitated, irritable or weepy before period *

Yes

Breasts are painful or swollen before period *

Yes

Have had a miscarriage in the 1st trimester *

Yes

Restless legs, especially at night *

Yes

Have had difficulty getting pregnant (after trying 6+ months) *

Yes

Fatigue / lethargy after eating *

Yes

Unexplained weight loss *

Yes

Abdominal pain and bloating *

Yes

Seemingly random lower back pain, stiff neck or joint pains *

Yes

Frequent diarrhea / loose stool *

Yes

Very foul smelling stool *

Yes

Yellowy / greasy stool *

Yes

Heartburn / GERD / acid reflux

Yes

Severe nausea or vomiting *

Yes

Excessive gas *

Yes

Seemingly random skin rashes *

Yes

Swollen lymph nodes (around throat or armpits) *

Yes

Frequent swelling or edema in extremities *

Yes

Frequent swelling or edema in abdomen

Yes

Noticeable bleeding with bowel movements *

Yes

Sudden, urgent need to have a bowel movement *

Yes

Mouth sores *

Yes

HOW are the symptoms you've indicated above impacting the quality of your life on a daily or weekly basis? Please describe below. Feel free to use this space to expand on any specific symptoms indicated above.