Welcome to Loving Menopausitivity™ QuestionnaireOn a scale of 0 to 10 with 0 being no major symptoms and 10 being severe symptoms, how has your experience been on your perimenopausal or menopausal journey? *12345678910What is your name? *What is your e-mail? *What is your age range? *30 - 4041 - 5051 - 60More than 60Prefer not to sayAre you currently struggling with perimenopausal or menopausal symptoms?YesNoIf you are experiencing symptoms, which symptoms of perimenopause or menopause are you experiencing?Hot Flashes / Night SweatsInsomnia / FatigueMood Swings / IrritabilityBrain Fog / Memory LapseAnxiety / Panic AttacksWeight GainTight Muscles / Joint PainDigestive Issues / BloatingChanges in Sex Drive / DrynessOthersChoose as many as you likeWhen was your last period?One month agoTwo to six months agoSeven to eleven months agoOne year or moreWhat have you tried to manage your perimenopausal or menopausal symptoms? *Please go into as much detail as you can.What is your type of diet?VeganVegetarianPescatarianNo restrictionsOtherChoose as many as you likeWhich types of food do you include in an average meal?Meat (e.g. Beef, Lamb, Pork)PoultryFishVegetablesFruitsBreadPastaRiceAvocadosOthersChoose as many as you likeWhich types of snacks do you consume regularly?Pastries or SweetsChipsNutsPopcornChocolateOthersChoose as many as you likeWhich types of drinks do you consume regularly?WaterCoffee / TeaGreen TeaAlcoholSoda PopJuiceOthersChoose as many as you likeDo you have any digestive issues? *BloatingAcid RefluxFlatulenceOthersNoneChoose as many as you likeDo you have any food sensitivities or allergies? *YesNoe.g. Gluten, dairy, soy, shellfish, etc.Are you taking any nutritional supplements? *YesNoWhich types of exercise are you doing regularly? *WalkingRunningCyclingOther Aerobic ExercisesWeights or Resistance TubingStretchingYoga / Tai ChiBalance ExerciseOtherNoneChoose as many as you likeHave you experienced changed in your sex drive? *Click to selectYesNoPrefer not to answerIf you experienced a decrease in your sex drive, which perimenopausal or menopausal symptoms might have affected you in this area?Insomnia / fatigueWeight GainMood Swings / IrritabilityAnxiety / Panic AttacksDigestive Issues / BloatingVaginal DrynessOtherNot ApplicableChoose as many as you likeWhat is your desired outcome?Find relief?Find ways to manage and prepare for your symptoms?Loving yourself?Living your best life?Feeling strong during menopause?Feeling healthy during menopause?Feeling sexy during menopause?Thriving during menopause?Loving Menopausitivity and beyond?Are you interested in my program?YesNoSubmit
