Do you experience hot flashes?
Yes
No
Sometimes
I'm not sure
Have you noticed any changes in your menstrual cycle?
Yes
No
i'm not sure
Have you experienced any unexpected mood swings?
Yes
No
I don't think so
Are you having difficulty sleeping?
Yes
No
Has your sex drive decreased?
Yes
No
I'm not sure
Have you experienced any changes in your urinary habits?
Yes
No
I'm not sure
Do you have difficulty concentrating?
Yes
No
I'm not sure
Have you experienced any unexpected weight gain?
Yes
No
I'm not sure
Are you experiencing any joint stiffness or pain?
Yes
No
What's Your Date of Birth
First Name
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