Women’s MyT Survey

Your Name:

Your Email:

City:

State:

ZIP:

Phone:

1. I have noticed a dramatic decrease in my energy levels.
 Yes No

2. For the most part, I have poor sleep quality.
 Yes No

3. I tend to experience night sweats and/or hot flashes.
 Yes No

4. I often find it difficult to lose weight.
 Yes No

5. I have noticed a loss of muscle mass in my body.
 Yes No

6. I tend to carry excess weight in my mid-section.
 Yes No

7. I have a decreased libido or loss of sexual desire.
 Yes No

8. I experience frequent feelings of anger/anxiety/depression.
 Yes No

9. I have had a hysterectomy. If yes, please specify the year:
 Yes No

10. I have had a tubal ligation. If yes, please specify the year:
 Yes No

Enter the Following Digits