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 fullname? *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?YesNoNot SureIf 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 likePlease tell me what is it.When 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 likePlease tell me what is it.Which types of food do you include in an average meal?Meat (e.g. Beef, Lamb, Pork)PoultryFishVegetablesFruitsBreadPastaRiceAvocadosOthersChoose as many as you likePlease tell me what is it.Which types of snacks do you consume regularly?Pastries or SweetsChipsNutsPopcornChocolateOthersChoose as many as you likePlease tell me what is it.Which types of drinks do you consume regularly?WaterCoffee / TeaGreen TeaAlcoholSoda PopJuiceOthersChoose as many as you likePlease tell me what is it.Do you have any digestive issues? *BloatingAcid RefluxFlatulenceOthersNoneChoose as many as you likePlease tell me what is it.Do you have any food sensitivities or allergies? *YesNoe.g. Gluten, dairy, soy, shellfish, etc.If yes, please choose...GlutenDairyShellfishSoyNutsOthersPlease tell me what is it.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 likePlease tell me what is it.Have 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 likePlease tell me what is it.What 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?I would like to invite you to a 30 minute heart to heart call with me to see where you are at in your journey . An invitation to a 30 minute Heart to Heart call Submit
