Name *

Email *

Phone Number *

Do you suffer from hot flashes? *

Do you suffer with night sweats? *

Do you notice yourself feeling more stressed, anxious or nervous? *

Have you recently gained weight primarily in your hips, abdomen, buttocks, or thighs? *

Do you have trouble sleeping? *

Is it harder to remember things *

Do you feel depressed? *

Have you lost interest in sex? *

Do you feel irritable, angry, or impatient, without control over your emotions? *

Do you have urinary leakage when you cough or sneeze? *