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Hormone Health Questionnaire
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Email
*
Your email
Name
*
Your answer
Age
*
Your answer
Please Describe your Main symptoms of concern
Your answer
Please select the one(s) that best describe(s) your Menstrual Cycle
Regular
Irrregular
Heavy Flow
Premenstrual Symptoms often
No longer Menstruating
Other:
Have you been diagnosed with an illness? or had surgery? (please give details)
Your answer
Are you currently taking any medication?(Please list)
Your answer
Are you currently taking any vitamins or supplements?(please list)
Your answer
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