iS YOUR BODY TRYING TO TELL YOU SOMETHING?

Name *

First Name

Last Name

Phone *

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Which describes you best? *

On hormonal birth control (the pill, patches, IUD, etc)

Not on birth control and have irregular periods

Not on birth control and have regular periods

Peri-menopausal

Post menopausal and no longer have a period

Pregnant/breastfeeding

What describes your periods best? *

I have heavy periods and may even be iron deficient

I have irregular, missing, or very light periods

I have really heavy, painful periods

I have irregular periods that either come more often or rarely

I no longer have a period

Check off all the symptoms that you experience surrounding your period: *

I'm often bloated during PMS/my period

Breast tenderness/swelling

I get migraines or headaches nearing/on my period

I feel irritable or have bad mood swings

I cry over nothing

I struggle with insomnia

I battle acne

I experience back pain during my periods

I often feel pain with urination or bowel movements during my period

I battle constipation or diarrhea during my periods

I struggle with fatigue

N/A

Check off all that applies to you: *

I have difficulty losing weight and hold it in my belly/hips

I'm struggling with weight gain even though my eating/movement habits haven't changed

I have excess body hair on my face, chest, and/or back

I have thinning hair

I'm losing my hair

I have very oily skin

I have puffiness in my face

I have extra skin on my neck or armpits (skin tags)

I have hot flashes/night sweats

I often feel cold when others don't

I have muscle weakness

I'm often constipated

I have brain fog/difficulty concentrating

I have problems with urinary leakage

I have vaginal dryness and/or pain during sex

I sometimes spot or bleed in between periods

I have decreased sex drive

I'm struggling with infertility

I struggle with depression/anxiety

N/A

Check off all the symptoms concerning your energy: *

I'm often exhausted in the morning, even after getting 7+ hours of sleep

I drink a lot of caffeine or take naps to get through my day

I'm having trouble sleeping

N/A

Have you been diagnosed with: *

I've been diagnosed with PCOS

I've been diagnosed with a thyroid disorder

I've been diagnosed with diabetes or I'm prediabetic

I've been diagnosed with endometriosis

I've been diagnosed with depression/anxiety

N/A